- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.97 / $2,486.15 / $2,486.15
| Professional | | $1,860.97 | $2,486.15 | $2,486.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.02 / $2,121.42 / $3,151.39
| Professional | | $1,725.02 | $2,121.42 | $3,151.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.15 / $2,486.15 / $3,493.25
| Professional | | $1,996.15 | $2,486.15 | $3,493.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.28 / $2,025.14 / $3,151.12
| Professional | | $1,819.28 | $2,025.14 | $3,151.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.97 / $2,486.15 / $2,486.15
| Professional | | $1,860.97 | $2,486.15 | $2,486.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.75 / $2,350.17 / $3,151.12
| Professional | | $1,659.75 | $2,350.17 | $3,151.12 |