- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.50 / $1,202.50 / $1,262.58
| Professional | | $1,202.50 | $1,202.50 | $1,262.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.80 / $1,282.01 / $1,992.43
| Professional | | $1,148.80 | $1,282.01 | $1,992.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.78 / $1,434.74 / $2,055.52
| Professional | | $980.78 | $1,434.74 | $2,055.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.50 / $1,395.46 / $2,140.71
| Professional | | $1,083.50 | $1,395.46 | $2,140.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.50 / $1,202.50 / $1,262.58
| Professional | | $1,202.50 | $1,202.50 | $1,262.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.25 / $1,573.92 / $1,894.89
| Professional | | $995.25 | $1,573.92 | $1,894.89 |