- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.91 / $2,025.39 / $2,749.96
| Professional | | $1,658.91 | $2,025.39 | $2,749.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.41 / $2,361.51 / $3,465.47
| Professional | | $1,911.41 | $2,361.51 | $3,465.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.04 / $2,749.96 / $3,871.60
| Professional | | $2,264.04 | $2,749.96 | $3,871.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.17 / $2,254.32 / $3,507.72
| Professional | | $2,025.17 | $2,254.32 | $3,507.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.91 / $2,736.64 / $3,289.12
| Professional | | $1,658.91 | $2,736.64 | $3,289.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.15 / $2,593.02 / $3,353.04
| Professional | | $1,897.15 | $2,593.02 | $3,353.04 |