- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.66 / $1,570.88 / $2,176.00
| Professional | | $1,334.66 | $1,570.88 | $2,176.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.54 / $1,870.98 / $2,745.62
| Professional | | $1,512.54 | $1,870.98 | $2,745.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.32 / $2,176.00 / $3,065.20
| Professional | | $1,790.32 | $2,176.00 | $3,065.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.51 / $1,786.06 / $2,779.11
| Professional | | $1,604.51 | $1,786.06 | $2,779.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.66 / $1,570.88 / $2,176.00
| Professional | | $1,334.66 | $1,570.88 | $2,176.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.83 / $2,053.48 / $2,795.68
| Professional | | $1,537.83 | $2,053.48 | $2,795.68 |