- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.96 / $1,211.96 / $1,211.96
| Professional | | $1,211.96 | $1,211.96 | $1,211.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.34 / $1,348.93 / $2,069.73
| Professional | | $1,042.34 | $1,348.93 | $2,069.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.52 / $1,390.97 / $2,151.00
| Professional | | $856.52 | $1,390.97 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.79 / $1,497.37 / $2,218.25
| Professional | | $1,249.79 | $1,497.37 | $2,218.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.96 / $1,211.96 / $1,211.96
| Professional | | $1,211.96 | $1,211.96 | $1,211.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.75 / $1,226.18 / $1,987.57
| Professional | | $977.75 | $1,226.18 | $1,987.57 |