- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.06 / $1,432.96 / $1,432.96
| Professional | | $1,146.06 | $1,432.96 | $1,432.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.58 / $1,225.44 / $1,820.55
| Professional | | $998.58 | $1,225.44 | $1,820.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.47 / $1,432.96 / $2,004.72
| Professional | | $1,208.47 | $1,432.96 | $2,004.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.91 / $1,169.82 / $1,820.24
| Professional | | $1,050.91 | $1,169.82 | $1,820.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.06 / $1,432.96 / $1,432.96
| Professional | | $1,146.06 | $1,432.96 | $1,432.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.80 / $1,483.21 / $1,790.08
| Professional | | $1,100.80 | $1,483.21 | $1,790.08 |