- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.62 / $1,971.08 / $1,971.08
| Professional | | $1,396.62 | $1,971.08 | $1,971.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.33 / $2,109.00 / $3,046.38
| Professional | | $1,885.33 | $2,109.00 | $3,046.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.81 / $2,252.58 / $3,501.94
| Professional | | $1,965.81 | $2,252.58 | $3,501.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.33 / $2,287.76 / $3,509.55
| Professional | | $1,776.33 | $2,287.76 | $3,509.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.62 / $1,971.08 / $1,971.08
| Professional | | $1,396.62 | $1,971.08 | $1,971.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.54 / $2,163.17 / $3,185.26
| Professional | | $1,580.54 | $2,163.17 | $3,185.26 |