- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.31 / $2,430.23 / $2,430.23
| Professional | | $1,824.31 | $2,430.23 | $2,430.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.20 / $2,072.64 / $3,081.37
| Professional | | $1,686.20 | $2,072.64 | $3,081.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.96 / $2,430.23 / $3,414.45
| Professional | | $1,906.96 | $2,430.23 | $3,414.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.44 / $1,978.56 / $3,078.64
| Professional | | $1,777.44 | $1,978.56 | $3,078.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.31 / $2,430.23 / $2,430.23
| Professional | | $1,824.31 | $2,430.23 | $2,430.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.58 / $2,289.19 / $3,094.19
| Professional | | $1,606.58 | $2,289.19 | $3,094.19 |