- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.52 / $1,142.52 / $1,224.76
| Professional | | $1,142.52 | $1,142.52 | $1,224.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.56 / $1,483.03 / $2,142.21
| Professional | | $1,253.56 | $1,483.03 | $2,142.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.04 / $1,599.37 / $2,417.80
| Professional | | $1,368.04 | $1,599.37 | $2,417.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.06 / $1,604.82 / $2,461.88
| Professional | | $1,246.06 | $1,604.82 | $2,461.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.52 / $1,142.52 / $1,224.76
| Professional | | $1,142.52 | $1,142.52 | $1,224.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.82 / $1,638.93 / $2,216.67
| Professional | | $1,234.82 | $1,638.93 | $2,216.67 |