- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.83 / $2,104.16 / $2,104.16
| Professional | | $1,539.83 | $2,104.16 | $2,104.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.65 / $2,280.37 / $3,247.97
| Professional | | $2,068.65 | $2,280.37 | $3,247.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.35 / $2,587.08 / $3,630.97
| Professional | | $1,798.35 | $2,587.08 | $3,630.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.31 / $2,442.29 / $3,746.60
| Professional | | $1,896.31 | $2,442.29 | $3,746.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.83 / $2,104.16 / $2,104.16
| Professional | | $1,539.83 | $2,104.16 | $2,104.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.61 / $2,442.29 / $3,303.76
| Professional | | $1,718.61 | $2,442.29 | $3,303.76 |