- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.64 / $1,396.79 / $1,396.79
| Professional | | $1,078.64 | $1,396.79 | $1,396.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.29 / $1,197.81 / $1,770.20
| Professional | | $975.29 | $1,197.81 | $1,770.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.78 / $1,396.79 / $1,960.44
| Professional | | $1,181.78 | $1,396.79 | $1,960.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.21 / $1,143.44 / $1,779.19
| Professional | | $1,027.21 | $1,143.44 | $1,779.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.64 / $1,396.79 / $1,396.79
| Professional | | $1,078.64 | $1,396.79 | $1,396.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.40 / $1,547.25 / $1,869.26
| Professional | | $1,100.40 | $1,547.25 | $1,869.26 |