- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.95 / $2,152.62 / $2,152.62
| Professional | | $1,562.95 | $2,152.62 | $2,152.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.00 / $1,838.17 / $2,723.21
| Professional | | $1,497.00 | $1,838.17 | $2,723.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.91 / $2,152.62 / $3,031.76
| Professional | | $1,664.91 | $2,152.62 | $3,031.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.37 / $1,754.74 / $2,730.38
| Professional | | $1,576.37 | $1,754.74 | $2,730.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.95 / $2,152.62 / $2,152.62
| Professional | | $1,562.95 | $2,152.62 | $2,152.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.53 / $1,989.26 / $2,400.83
| Professional | | $1,404.53 | $1,989.26 | $2,400.83 |