- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.54 / $2,487.04 / $2,487.04
| Professional | | $1,841.54 | $2,487.04 | $2,487.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.80 / $2,121.42 / $3,152.27
| Professional | | $1,726.80 | $2,121.42 | $3,152.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.46 / $2,487.04 / $3,495.99
| Professional | | $2,022.46 | $2,487.04 | $3,495.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.28 / $2,025.14 / $3,151.12
| Professional | | $1,819.28 | $2,025.14 | $3,151.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.54 / $2,487.04 / $2,487.04
| Professional | | $1,841.54 | $2,487.04 | $2,487.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.02 / $2,345.59 / $2,830.89
| Professional | | $1,683.02 | $2,345.59 | $2,830.89 |