- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.61 / $1,000.61 / $1,208.48
| Professional | | $1,000.61 | $1,000.61 | $1,208.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.79 / $1,364.62 / $1,971.15
| Professional | | $1,161.79 | $1,364.62 | $1,971.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.99 / $1,468.19 / $2,249.91
| Professional | | $1,256.99 | $1,468.19 | $2,249.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.23 / $1,473.67 / $2,260.69
| Professional | | $1,144.23 | $1,473.67 | $2,260.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.61 / $1,000.61 / $1,208.48
| Professional | | $1,000.61 | $1,000.61 | $1,208.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.92 / $1,499.57 / $2,066.40
| Professional | | $1,067.92 | $1,499.57 | $2,066.40 |