- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.34 / $1,746.48 / $1,746.48
| Professional | | $1,278.34 | $1,746.48 | $1,746.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.91 / $1,496.18 / $2,211.17
| Professional | | $1,213.91 | $1,496.18 | $2,211.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.95 / $1,746.48 / $2,461.48
| Professional | | $1,412.95 | $1,746.48 | $2,461.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.08 / $1,428.27 / $2,222.39
| Professional | | $1,283.08 | $1,428.27 | $2,222.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.34 / $1,746.48 / $1,746.48
| Professional | | $1,278.34 | $1,746.48 | $1,746.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.54 / $1,703.93 / $2,222.39
| Professional | | $1,168.54 | $1,703.93 | $2,222.39 |