- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.14 / $1,360.14 / $2,273.19
| Professional | | $1,360.14 | $1,360.14 | $2,273.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.24 / $1,954.32 / $2,867.19
| Professional | | $1,579.24 | $1,954.32 | $2,867.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.88 / $2,273.19 / $3,199.78
| Professional | | $1,865.88 | $2,273.19 | $3,199.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.98 / $1,865.62 / $2,902.90
| Professional | | $1,675.98 | $1,865.62 | $2,902.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.14 / $1,661.80 / $2,273.19
| Professional | | $1,360.14 | $1,661.80 | $2,273.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.46 / $2,145.00 / $2,918.16
| Professional | | $1,542.46 | $2,145.00 | $2,918.16 |