- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.52 / $1,764.37 / $1,764.37
| Professional | | $1,312.52 | $1,764.37 | $1,764.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.90 / $1,518.64 / $2,227.40
| Professional | | $1,225.90 | $1,518.64 | $2,227.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.12 / $1,764.37 / $2,486.19
| Professional | | $1,450.12 | $1,764.37 | $2,486.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.34 / $1,449.71 / $2,255.75
| Professional | | $1,302.34 | $1,449.71 | $2,255.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.52 / $1,764.37 / $1,764.37
| Professional | | $1,312.52 | $1,764.37 | $1,764.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.96 / $1,661.29 / $2,005.01
| Professional | | $1,232.96 | $1,661.29 | $2,005.01 |