- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.08 / $1,188.08 / $1,260.60
| Professional | | $1,188.08 | $1,188.08 | $1,260.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.36 / $1,553.59 / $2,255.39
| Professional | | $1,293.36 | $1,553.59 | $2,255.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.37 / $1,681.55 / $2,553.86
| Professional | | $1,376.37 | $1,681.55 | $2,553.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.38 / $1,686.37 / $2,586.98
| Professional | | $1,309.38 | $1,686.37 | $2,586.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.08 / $1,188.08 / $1,289.39
| Professional | | $1,188.08 | $1,188.08 | $1,289.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.61 / $1,757.15 / $2,586.98
| Professional | | $1,260.61 | $1,757.15 | $2,586.98 |