- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.19 / $1,811.14 / $1,811.14
| Professional | | $1,357.19 | $1,811.14 | $1,811.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.13 / $1,972.54 / $2,849.27
| Professional | | $1,730.13 | $1,972.54 | $2,849.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.62 / $1,963.60 / $3,257.40
| Professional | | $1,835.62 | $1,963.60 | $3,257.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.76 / $2,142.78 / $3,287.13
| Professional | | $1,663.76 | $2,142.78 | $3,287.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.19 / $1,811.14 / $1,811.14
| Professional | | $1,357.19 | $1,811.14 | $1,811.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.62 / $2,080.29 / $2,990.91
| Professional | | $1,707.62 | $2,080.29 | $2,990.91 |