- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.81 / $1,877.04 / $1,877.04
| Professional | | $1,339.81 | $1,877.04 | $1,877.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.86 / $2,043.41 / $2,951.66
| Professional | | $1,718.86 | $2,043.41 | $2,951.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.86 / $2,031.97 / $3,370.81
| Professional | | $1,889.86 | $2,031.97 | $3,370.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.01 / $2,219.09 / $3,404.20
| Professional | | $1,723.01 | $2,219.09 | $3,404.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.81 / $1,877.04 / $1,877.04
| Professional | | $1,339.81 | $1,877.04 | $1,877.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.32 / $2,197.79 / $3,096.62
| Professional | | $1,701.32 | $2,197.79 | $3,096.62 |