- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.83 / $1,517.36 / $1,517.36
| Professional | | $1,251.83 | $1,517.36 | $1,517.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.83 / $1,298.42 / $1,926.49
| Professional | | $1,056.83 | $1,298.42 | $1,926.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.18 / $1,517.36 / $2,122.02
| Professional | | $1,279.18 | $1,517.36 | $2,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.49 / $1,239.49 / $1,928.65
| Professional | | $1,113.49 | $1,239.49 | $1,928.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.83 / $1,517.36 / $1,517.36
| Professional | | $1,251.83 | $1,517.36 | $1,517.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.03 / $1,674.68 / $1,923.70
| Professional | | $1,191.03 | $1,674.68 | $1,923.70 |