- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.81 / $1,720.24 / $1,720.24
| Professional | | $1,254.81 | $1,720.24 | $1,720.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.55 / $1,472.87 / $2,168.80
| Professional | | $1,195.55 | $1,472.87 | $2,168.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.73 / $1,720.24 / $2,420.64
| Professional | | $1,416.73 | $1,720.24 | $2,420.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,406.01 / $2,187.75
| Professional | | $1,263.08 | $1,406.01 | $2,187.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.81 / $1,720.24 / $1,720.24
| Professional | | $1,254.81 | $1,720.24 | $1,720.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.17 / $1,621.80 / $2,097.15
| Professional | | $1,238.17 | $1,621.80 | $2,097.15 |