- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.86 / $1,463.22 / $1,463.22
| Professional | | $1,080.86 | $1,463.22 | $1,463.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.35 / $1,232.78 / $1,862.73
| Professional | | $1,012.35 | $1,232.78 | $1,862.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.21 / $1,463.22 / $2,040.77
| Professional | | $1,230.21 | $1,463.22 | $2,040.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.21 / $1,176.83 / $1,831.15
| Professional | | $1,057.21 | $1,176.83 | $1,831.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.86 / $1,463.22 / $1,463.22
| Professional | | $1,080.86 | $1,463.22 | $1,463.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.42 / $1,398.36 / $1,796.10
| Professional | | $1,124.42 | $1,398.36 | $1,796.10 |