- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.41 / $1,176.41 / $1,236.58
| Professional | | $1,176.41 | $1,176.41 | $1,236.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.15 / $1,538.91 / $2,232.48
| Professional | | $1,281.15 | $1,538.91 | $2,232.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.44 / $1,664.57 / $2,528.84
| Professional | | $1,408.44 | $1,664.57 | $2,528.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.05 / $1,669.20 / $2,560.65
| Professional | | $1,296.05 | $1,669.20 | $2,560.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.41 / $1,176.41 / $1,275.91
| Professional | | $1,176.41 | $1,176.41 | $1,275.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.79 / $1,669.20 / $2,315.13
| Professional | | $1,290.79 | $1,669.20 | $2,315.13 |