- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.97 / $1,840.97 / $2,227.12
| Professional | | $1,840.97 | $1,840.97 | $2,227.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.86 / $2,205.21 / $3,255.68
| Professional | | $1,950.86 | $2,205.21 | $3,255.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.43 / $2,257.88 / $3,395.86
| Professional | | $1,708.43 | $2,257.88 | $3,395.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.65 / $2,369.32 / $3,634.66
| Professional | | $1,839.65 | $2,369.32 | $3,634.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.97 / $1,840.97 / $2,227.12
| Professional | | $1,840.97 | $1,840.97 | $2,227.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.51 / $2,241.94 / $3,145.84
| Professional | | $1,588.51 | $2,241.94 | $3,145.84 |