- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,657.34
| Professional | | $1,640.93 | $1,640.93 | $1,657.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.09 / $1,932.29 / $2,222.13
| Professional | | $1,681.09 | $1,932.29 | $2,222.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.02 / $1,969.11 / $2,297.30
| Professional | | $1,805.02 | $1,969.11 | $2,297.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.96 / $1,640.93 / $2,461.40
| Professional | | $1,503.96 | $1,640.93 | $2,461.40 |