- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.16 / $1,798.65 / $2,711.67
| Professional | | $1,528.16 | $1,798.65 | $2,711.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,879.99 / $2,315.73 / $3,429.22
| Professional | | $1,879.99 | $2,315.73 | $3,429.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.07 / $2,711.67 / $3,800.29
| Professional | | $2,118.07 | $2,711.67 | $3,800.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.92 / $2,210.63 / $3,439.74
| Professional | | $1,985.92 | $2,210.63 | $3,439.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.16 / $1,866.54 / $2,711.67
| Professional | | $1,528.16 | $1,866.54 | $2,711.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.40 / $2,566.37 / $3,097.34
| Professional | | $1,809.40 | $2,566.37 | $3,097.34 |