- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.70 / $2,332.44 / $2,332.44
| Professional | | $1,736.70 | $2,332.44 | $2,332.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.78 / $1,989.30 / $2,955.20
| Professional | | $1,618.78 | $1,989.30 | $2,955.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.96 / $2,332.44 / $3,277.64
| Professional | | $1,869.96 | $2,332.44 | $3,277.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,705.97 / $1,899.01 / $2,954.86
| Professional | | $1,705.97 | $1,899.01 | $2,954.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.70 / $2,332.44 / $2,332.44
| Professional | | $1,736.70 | $2,332.44 | $2,332.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.77 / $2,203.73 / $2,659.69
| Professional | | $1,560.77 | $2,203.73 | $2,659.69 |