- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.07 / $1,049.07 / $1,250.09
| Professional | | $1,049.07 | $1,049.07 | $1,250.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.81 / $1,446.06 / $2,088.78
| Professional | | $1,205.81 | $1,446.06 | $2,088.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.49 / $1,551.33 / $2,401.64
| Professional | | $1,309.49 | $1,551.33 | $2,401.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.81 / $1,554.27 / $2,384.33
| Professional | | $1,206.81 | $1,554.27 | $2,384.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.07 / $1,049.07 / $1,250.09
| Professional | | $1,049.07 | $1,049.07 | $1,250.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.47 / $1,552.97 / $2,197.69
| Professional | | $1,104.47 | $1,552.97 | $2,197.69 |