- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.60 / $1,009.60 / $1,870.14
| Professional | | $1,009.60 | $1,009.60 | $1,870.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.48 / $1,346.76 / $2,116.42
| Professional | | $1,174.48 | $1,346.76 | $2,116.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.66 / $1,510.01 / $2,163.35
| Professional | | $1,233.66 | $1,510.01 | $2,163.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.01 / $1,445.06 / $2,216.80
| Professional | | $1,122.01 | $1,445.06 | $2,216.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.60 / $1,009.60 / $1,870.14
| Professional | | $1,009.60 | $1,009.60 | $1,870.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.09 / $1,508.33 / $1,998.96
| Professional | | $1,098.09 | $1,508.33 | $1,998.96 |