- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $3,548.13
| Professional | | $1,479.11 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $3,162.28
| Professional | | $1,513.56 | $2,344.23 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $3,548.13
| Professional | | $1,905.46 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $3,235.94
| Professional | | $1,905.46 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $4,786.30
| Professional | | $1,479.11 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,388.44
| Professional | | $1,621.81 | $2,344.23 | $3,388.44 |