- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.64 / $2,367.53 / $2,367.53
| Professional | | $1,337.64 | $2,367.53 | $2,367.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.84 / $1,994.48 / $3,015.31
| Professional | | $1,637.84 | $1,994.48 | $3,015.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.58 / $2,367.53 / $3,302.17
| Professional | | $1,548.58 | $2,367.53 | $3,302.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.42 / $1,903.95 / $2,962.55
| Professional | | $1,710.42 | $1,903.95 | $2,962.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.64 / $2,367.53 / $2,367.53
| Professional | | $1,337.64 | $2,367.53 | $2,367.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.21 / $2,259.33 / $2,968.81
| Professional | | $1,473.21 | $2,259.33 | $2,968.81 |