- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.51 / $1,907.74 / $2,688.20
| Professional | | $1,623.51 | $1,907.74 | $2,688.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.52 / $2,304.94 / $3,392.43
| Professional | | $1,865.52 | $2,304.94 | $3,392.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.77 / $2,688.20 / $3,776.80
| Professional | | $2,211.77 | $2,688.20 | $3,776.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.66 / $2,200.32 / $3,423.70
| Professional | | $1,976.66 | $2,200.32 | $3,423.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.51 / $1,907.74 / $2,688.20
| Professional | | $1,623.51 | $1,907.74 | $2,688.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.64 / $2,623.76 / $3,438.81
| Professional | | $1,905.64 | $2,623.76 | $3,438.81 |