- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.96 / $2,189.17 / $2,189.17
| Professional | | $1,604.96 | $2,189.17 | $2,189.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.36 / $1,883.08 / $2,761.20
| Professional | | $1,521.36 | $1,883.08 | $2,761.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.11 / $2,189.17 / $3,082.96
| Professional | | $1,801.11 | $2,189.17 | $3,082.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.88 / $1,797.60 / $2,797.07
| Professional | | $1,614.88 | $1,797.60 | $2,797.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.96 / $2,189.17 / $2,189.17
| Professional | | $1,604.96 | $2,189.17 | $2,189.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.69 / $2,065.51 / $2,492.86
| Professional | | $1,460.69 | $2,065.51 | $2,492.86 |