- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.71 / $1,602.65 / $1,602.65
| Professional | | $1,294.71 | $1,602.65 | $1,602.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.83 / $1,370.09 / $2,036.78
| Professional | | $1,116.83 | $1,370.09 | $2,036.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.67 / $1,602.65 / $2,241.80
| Professional | | $1,183.67 | $1,602.65 | $2,241.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.96 / $1,307.91 / $2,035.11
| Professional | | $1,174.96 | $1,307.91 | $2,035.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.71 / $1,602.65 / $1,602.65
| Professional | | $1,294.71 | $1,602.65 | $1,602.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.66 / $1,541.41 / $1,860.32
| Professional | | $893.66 | $1,541.41 | $1,860.32 |