- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.09 / $2,449.94 / $2,449.94
| Professional | | $1,560.09 | $2,449.94 | $2,449.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.42 / $2,267.56 / $3,250.40
| Professional | | $1,927.42 | $2,267.56 | $3,250.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.56 / $2,449.94 / $3,626.27
| Professional | | $1,973.56 | $2,449.94 | $3,626.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.03 / $1,970.32 / $3,065.82
| Professional | | $1,770.03 | $1,970.32 | $3,065.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.09 / $2,449.94 / $2,449.94
| Professional | | $1,560.09 | $2,449.94 | $2,449.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.83 / $1,706.97 / $2,961.30
| Professional | | $1,216.83 | $1,706.97 | $2,961.30 |