- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.56 / $2,565.21 / $2,565.21
| Professional | | $1,874.56 | $2,565.21 | $2,565.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.15 / $2,200.44 / $3,238.25
| Professional | | $1,781.15 | $2,200.44 | $3,238.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.50 / $2,565.21 / $3,606.98
| Professional | | $2,111.50 | $2,565.21 | $3,606.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.05 / $2,100.57 / $3,268.49
| Professional | | $1,887.05 | $2,100.57 | $3,268.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.56 / $2,565.21 / $2,565.21
| Professional | | $1,874.56 | $2,565.21 | $2,565.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.48 / $2,422.69 / $3,286.17
| Professional | | $1,776.48 | $2,422.69 | $3,286.17 |