- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.01 / $2,075.96 / $2,075.96
| Professional | | $1,616.01 | $2,075.96 | $2,075.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.76 / $1,772.97 / $2,640.04
| Professional | | $1,444.76 | $1,772.97 | $2,640.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.29 / $2,075.96 / $2,898.56
| Professional | | $1,747.29 | $2,075.96 | $2,898.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.45 / $1,692.49 / $2,633.51
| Professional | | $1,520.45 | $1,692.49 | $2,633.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.01 / $2,075.96 / $2,075.96
| Professional | | $1,616.01 | $2,075.96 | $2,075.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.51 / $2,014.50 / $2,624.83
| Professional | | $1,552.51 | $2,014.50 | $2,624.83 |