- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.73 / $1,883.75 / $1,883.75
| Professional | | $1,407.73 | $1,883.75 | $1,883.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.50 / $1,539.42 / $2,377.87
| Professional | | $1,308.50 | $1,539.42 | $2,377.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.05 / $1,883.75 / $2,636.48
| Professional | | $1,545.05 | $1,883.75 | $2,636.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.75 / $1,435.69 / $2,233.92
| Professional | | $1,289.75 | $1,435.69 | $2,233.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.73 / $1,883.75 / $1,883.75
| Professional | | $1,407.73 | $1,883.75 | $1,883.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.19 / $1,788.39 / $2,312.57
| Professional | | $1,330.19 | $1,788.39 | $2,312.57 |