- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.78 / $1,119.78 / $1,263.65
| Professional | | $1,119.78 | $1,119.78 | $1,263.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.98 / $1,162.46 / $1,786.11
| Professional | | $1,054.98 | $1,162.46 | $1,786.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.18 / $1,305.54 / $1,870.41
| Professional | | $1,046.18 | $1,305.54 | $1,870.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.30 / $1,250.95 / $1,919.02
| Professional | | $971.30 | $1,250.95 | $1,919.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.78 / $1,119.78 / $1,263.65
| Professional | | $1,119.78 | $1,119.78 | $1,263.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.31 / $1,319.90 / $1,731.49
| Professional | | $878.31 | $1,319.90 | $1,731.49 |