- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.03 / $1,734.17 / $1,734.17
| Professional | | $1,371.03 | $1,734.17 | $1,734.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.62 / $1,868.65 / $2,699.20
| Professional | | $1,654.62 | $1,868.65 | $2,699.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.60 / $2,004.17 / $3,116.33
| Professional | | $1,759.60 | $2,004.17 | $3,116.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.11 / $2,018.31 / $3,096.19
| Professional | | $1,567.11 | $2,018.31 | $3,096.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.03 / $1,734.17 / $1,734.17
| Professional | | $1,371.03 | $1,734.17 | $1,734.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.43 / $2,185.54 / $2,840.76
| Professional | | $1,744.43 | $2,185.54 | $2,840.76 |