- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.29 / $2,612.04 / $2,612.04
| Professional | | $1,940.29 | $2,612.04 | $2,612.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.91 / $2,227.21 / $3,311.85
| Professional | | $1,812.91 | $2,227.21 | $3,311.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,148.16 / $2,612.04 / $3,670.08
| Professional | | $2,148.16 | $2,612.04 | $3,670.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.01 / $2,126.13 / $3,308.26
| Professional | | $1,910.01 | $2,126.13 | $3,308.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.29 / $2,612.04 / $2,612.04
| Professional | | $1,940.29 | $2,612.04 | $2,612.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.01 / $2,551.34 / $3,326.16
| Professional | | $1,910.01 | $2,551.34 | $3,326.16 |