- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.33 / $1,667.80 / $1,667.80
| Professional | | $1,233.33 | $1,667.80 | $1,667.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.83 / $1,426.66 / $2,109.83
| Professional | | $1,158.83 | $1,426.66 | $2,109.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.38 / $1,667.80 / $2,349.17
| Professional | | $1,294.38 | $1,667.80 | $2,349.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.47 / $1,361.91 / $2,119.13
| Professional | | $1,223.47 | $1,361.91 | $2,119.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.33 / $1,667.80 / $1,667.80
| Professional | | $1,233.33 | $1,667.80 | $1,667.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.94 / $1,587.61 / $2,132.13
| Professional | | $1,122.94 | $1,587.61 | $2,132.13 |