- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.28 / $1,508.08 / $1,508.08
| Professional | | $1,131.28 | $1,508.08 | $1,508.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.88 / $1,619.06 / $2,338.67
| Professional | | $1,471.88 | $1,619.06 | $2,338.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.52 / $1,749.20 / $2,663.85
| Professional | | $1,523.52 | $1,749.20 | $2,663.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.59 / $1,753.62 / $2,690.14
| Professional | | $1,361.59 | $1,753.62 | $2,690.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.28 / $1,508.08 / $1,508.08
| Professional | | $1,131.28 | $1,508.08 | $1,508.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.04 / $1,751.39 / $2,439.69
| Professional | | $1,370.04 | $1,751.39 | $2,439.69 |