- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.07 / $2,654.46 / $2,654.46
| Professional | | $1,969.07 | $2,654.46 | $2,654.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.57 / $2,275.15 / $3,350.26
| Professional | | $1,842.57 | $2,275.15 | $3,350.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.54 / $2,654.46 / $3,730.03
| Professional | | $2,184.54 | $2,654.46 | $3,730.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.11 / $2,171.88 / $3,379.45
| Professional | | $1,951.11 | $2,171.88 | $3,379.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.07 / $2,654.46 / $2,654.46
| Professional | | $1,969.07 | $2,654.46 | $2,654.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.27 / $2,620.41 / $3,162.57
| Professional | | $1,866.27 | $2,620.41 | $3,162.57 |