- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.78 / $2,327.86 / $2,327.86
| Professional | | $1,740.78 | $2,327.86 | $2,327.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.19 / $1,980.67 / $2,955.95
| Professional | | $1,614.19 | $1,980.67 | $2,955.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.34 / $2,327.86 / $3,265.38
| Professional | | $1,765.34 | $2,327.86 | $3,265.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.57 / $1,890.76 / $2,942.02
| Professional | | $1,698.57 | $1,890.76 | $2,942.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.78 / $2,327.86 / $2,327.86
| Professional | | $1,740.78 | $2,327.86 | $2,327.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.36 / $2,427.63 / $2,954.76
| Professional | | $1,554.36 | $2,427.63 | $2,954.76 |