- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.88 / $1,054.88 / $1,847.04
| Professional | | $1,054.88 | $1,054.88 | $1,847.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.52 / $1,402.12 / $2,217.01
| Professional | | $1,224.52 | $1,402.12 | $2,217.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.27 / $1,582.34 / $2,266.98
| Professional | | $1,264.27 | $1,582.34 | $2,266.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.33 / $1,513.73 / $2,322.14
| Professional | | $1,175.33 | $1,513.73 | $2,322.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.88 / $1,054.88 / $1,847.04
| Professional | | $1,054.88 | $1,054.88 | $1,847.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.33 / $1,564.23 / $2,095.14
| Professional | | $1,175.33 | $1,564.23 | $2,095.14 |