- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.77 / $1,426.77 / $2,583.98
| Professional | | $1,426.77 | $1,426.77 | $2,583.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.44 / $2,208.65 / $3,265.24
| Professional | | $1,792.44 | $2,208.65 | $3,265.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.19 / $2,583.98 / $3,624.46
| Professional | | $1,849.19 | $2,583.98 | $3,624.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.08 / $2,108.40 / $3,280.67
| Professional | | $1,894.08 | $2,108.40 | $3,280.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.77 / $1,743.60 / $2,583.98
| Professional | | $1,426.77 | $1,743.60 | $2,583.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.29 / $2,442.19 / $3,280.67
| Professional | | $1,722.29 | $2,442.19 | $3,280.67 |