- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.98 / $2,354.59 / $2,354.59
| Professional | | $2,154.98 | $2,354.59 | $2,354.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.31 / $1,991.03 / $3,339.43
| Professional | | $1,628.31 | $1,991.03 | $3,339.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.67 / $2,485.08 / $3,290.68
| Professional | | $1,983.67 | $2,485.08 | $3,290.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.45 / $1,900.65 / $2,957.41
| Professional | | $1,707.45 | $1,900.65 | $2,957.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.98 / $2,354.59 / $2,354.59
| Professional | | $2,154.98 | $2,354.59 | $2,354.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.90 / $2,706.54 / $2,986.53
| Professional | | $2,122.90 | $2,706.54 | $2,986.53 |