- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.93 / $1,314.25 / $1,314.25
| Professional | | $1,036.93 | $1,314.25 | $1,314.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.92 / $998.75 / $1,646.84
| Professional | | $812.92 | $998.75 | $1,646.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.60 / $1,235.28 / $1,633.33
| Professional | | $984.60 | $1,235.28 | $1,633.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.50 / $953.42 / $1,483.52
| Professional | | $856.50 | $953.42 | $1,483.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.93 / $1,314.25 / $1,314.25
| Professional | | $1,036.93 | $1,314.25 | $1,314.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.23 / $1,329.13 / $1,481.75
| Professional | | $947.23 | $1,329.13 | $1,481.75 |