- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.46 / $1,999.61 / $1,999.61
| Professional | | $1,486.46 | $1,999.61 | $1,999.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,970.24 / $2,183.98 / $3,093.45
| Professional | | $1,970.24 | $2,183.98 | $3,093.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.42 / $2,458.54 / $3,454.89
| Professional | | $1,961.42 | $2,458.54 | $3,454.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.69 / $2,326.87 / $3,569.54
| Professional | | $1,806.69 | $2,326.87 | $3,569.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.46 / $1,999.61 / $1,999.61
| Professional | | $1,486.46 | $1,999.61 | $1,999.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.66 / $2,322.07 / $3,143.91
| Professional | | $1,840.66 | $2,322.07 | $3,143.91 |