- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.50 / $2,309.42 / $2,309.42
| Professional | | $1,698.50 | $2,309.42 | $2,309.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.95 / $1,982.39 / $2,913.56
| Professional | | $1,603.95 | $1,982.39 | $2,913.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.86 / $2,309.42 / $3,248.04
| Professional | | $1,900.86 | $2,309.42 | $3,248.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.05 / $1,892.41 / $2,944.59
| Professional | | $1,700.05 | $1,892.41 | $2,944.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.50 / $2,309.42 / $2,309.42
| Professional | | $1,698.50 | $2,309.42 | $2,309.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.88 / $2,179.87 / $2,818.80
| Professional | | $1,633.88 | $2,179.87 | $2,818.80 |