- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.38 / $1,456.07 / $1,456.07
| Professional | | $1,179.38 | $1,456.07 | $1,456.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.12 / $1,247.46 / $1,992.82
| Professional | | $1,014.12 | $1,247.46 | $1,992.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.76 / $1,456.07 / $2,036.72
| Professional | | $1,226.76 | $1,456.07 | $2,036.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.80 / $1,190.84 / $1,852.96
| Professional | | $1,069.80 | $1,190.84 | $1,852.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.38 / $1,456.07 / $1,456.07
| Professional | | $1,179.38 | $1,456.07 | $1,456.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.39 / $1,505.72 / $1,817.25
| Professional | | $1,085.39 | $1,505.72 | $1,817.25 |