- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.43 / $1,427.43 / $1,427.43
| Professional | | $1,427.43 | $1,427.43 | $1,427.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.95 / $2,205.29 / $3,388.48
| Professional | | $1,738.95 | $2,205.29 | $3,388.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.05 / $2,454.53 / $3,826.90
| Professional | | $1,376.05 | $2,454.53 | $3,826.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.98 / $2,654.98 / $3,933.16
| Professional | | $2,215.98 | $2,654.98 | $3,933.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.43 / $1,427.43 / $1,427.43
| Professional | | $1,427.43 | $1,427.43 | $1,427.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.08 / $2,265.41 / $3,524.94
| Professional | | $1,737.08 | $2,265.41 | $3,524.94 |