- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.29 / $2,275.37 / $2,275.37
| Professional | | $1,677.29 | $2,275.37 | $2,275.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.66 / $1,955.62 / $2,870.40
| Professional | | $1,580.66 | $1,955.62 | $2,870.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.53 / $2,275.37 / $3,202.78
| Professional | | $1,872.53 | $2,275.37 | $3,202.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.09 / $1,866.85 / $2,904.82
| Professional | | $1,677.09 | $1,866.85 | $2,904.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.29 / $2,275.37 / $2,275.37
| Professional | | $1,677.29 | $2,275.37 | $2,275.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.37 / $2,366.29 / $2,904.82
| Professional | | $1,610.37 | $2,366.29 | $2,904.82 |