- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.45 / $1,764.19 / $2,075.98
| Professional | | $1,378.45 | $1,764.19 | $2,075.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.97 / $2,269.85 / $3,167.20
| Professional | | $1,753.97 | $2,269.85 | $3,167.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.93 / $2,491.19 / $3,617.36
| Professional | | $1,681.93 | $2,491.19 | $3,617.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.76 / $2,375.04 / $3,643.44
| Professional | | $2,052.76 | $2,375.04 | $3,643.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.45 / $1,805.63 / $2,075.98
| Professional | | $1,378.45 | $1,805.63 | $2,075.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.27 / $2,136.23 / $3,297.29
| Professional | | $1,473.27 | $2,136.23 | $3,297.29 |