- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.50 / $2,308.77 / $3,066.61
| Professional | | $1,893.50 | $2,308.77 | $3,066.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.31 / $2,617.14 / $3,880.15
| Professional | | $2,125.31 | $2,617.14 | $3,880.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,523.73 / $3,066.61 / $4,295.04
| Professional | | $2,523.73 | $3,066.61 | $4,295.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.39 / $2,498.34 / $3,887.42
| Professional | | $2,244.39 | $2,498.34 | $3,887.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.50 / $3,009.24 / $3,633.86
| Professional | | $1,893.50 | $3,009.24 | $3,633.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.26 / $2,999.97 / $4,434.30
| Professional | | $2,113.26 | $2,999.97 | $4,434.30 |