- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $4,073.80
| Professional | | $1,548.82 | $1,949.84 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $3,630.78
| Professional | | $1,548.82 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $3,801.89
| Professional | | $1,905.46 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $4,265.80
| Professional | | $1,905.46 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $4,786.30
| Professional | | $1,548.82 | $2,187.76 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $3,388.44
| Professional | | $1,479.11 | $2,238.72 | $3,388.44 |