- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.19 / $1,478.97 / $1,478.97
| Professional | | $1,242.19 | $1,478.97 | $1,478.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.77 / $1,266.46 / $1,874.75
| Professional | | $1,031.77 | $1,266.46 | $1,874.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.22 / $1,478.97 / $2,072.23
| Professional | | $1,248.22 | $1,478.97 | $2,072.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.08 / $1,208.98 / $1,881.17
| Professional | | $1,086.08 | $1,208.98 | $1,881.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.19 / $1,478.97 / $1,478.97
| Professional | | $1,242.19 | $1,478.97 | $1,478.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.72 / $1,550.91 / $1,877.90
| Professional | | $1,101.72 | $1,550.91 | $1,877.90 |