- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.09 / $2,132.86 / $2,132.86
| Professional | | $1,575.09 | $2,132.86 | $2,132.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.58 / $2,294.13 / $3,308.37
| Professional | | $2,085.58 | $2,294.13 | $3,308.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.92 / $2,446.67 / $3,835.91
| Professional | | $1,966.92 | $2,446.67 | $3,835.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.01 / $2,472.81 / $3,793.42
| Professional | | $1,920.01 | $2,472.81 | $3,793.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.09 / $2,132.86 / $2,132.86
| Professional | | $1,575.09 | $2,132.86 | $2,132.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.96 / $2,641.70 / $3,499.40
| Professional | | $1,927.96 | $2,641.70 | $3,499.40 |