- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.90 / $1,746.86 / $2,118.88
| Professional | | $1,312.90 | $1,746.86 | $2,118.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.72 / $1,684.02 / $2,428.96
| Professional | | $1,460.72 | $1,684.02 | $2,428.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $2,362.62 / $3,415.15
| Professional | | $1,609.27 | $2,362.62 | $3,415.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.58 / $1,981.86 / $3,517.60
| Professional | | $1,607.58 | $1,981.86 | $3,517.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.90 / $1,746.86 / $2,118.88
| Professional | | $1,312.90 | $1,746.86 | $2,118.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.58 / $2,439.86 / $3,398.64
| Professional | | $1,607.58 | $2,439.86 | $3,398.64 |