- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.23 / $2,127.75 / $2,127.75
| Professional | | $1,564.23 | $2,127.75 | $2,127.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.58 / $1,817.01 / $2,696.28
| Professional | | $1,477.58 | $1,817.01 | $2,696.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.30 / $2,127.75 / $2,992.99
| Professional | | $1,603.30 | $2,127.75 | $2,992.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.22 / $1,734.54 / $2,698.94
| Professional | | $1,558.22 | $1,734.54 | $2,698.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.23 / $2,127.75 / $2,127.75
| Professional | | $1,564.23 | $2,127.75 | $2,127.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.39 / $2,001.17 / $2,587.73
| Professional | | $1,413.39 | $2,001.17 | $2,587.73 |