- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.61 / $2,461.48 / $2,461.48
| Professional | | $1,817.61 | $2,461.48 | $2,461.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.79 / $2,111.50 / $3,104.13
| Professional | | $1,708.79 | $2,111.50 | $3,104.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,024.73 / $2,461.48 / $3,460.90
| Professional | | $2,024.73 | $2,461.48 | $3,460.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.77 / $2,015.66 / $3,136.37
| Professional | | $1,810.77 | $2,015.66 | $3,136.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.61 / $2,461.48 / $2,461.48
| Professional | | $1,817.61 | $2,461.48 | $2,461.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.43 / $2,332.12 / $3,136.37
| Professional | | $1,910.43 | $2,332.12 | $3,136.37 |