- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.88 / $2,686.79 / $2,686.79
| Professional | | $1,983.88 | $2,686.79 | $2,686.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.16 / $2,305.37 / $3,390.41
| Professional | | $1,865.16 | $2,305.37 | $3,390.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.71 / $2,686.79 / $3,777.06
| Professional | | $2,210.71 | $2,686.79 | $3,777.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.03 / $2,200.73 / $3,424.35
| Professional | | $1,977.03 | $2,200.73 | $3,424.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.88 / $2,686.79 / $2,686.79
| Professional | | $1,983.88 | $2,686.79 | $2,686.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,922.69 / $2,537.15 / $3,280.80
| Professional | | $1,922.69 | $2,537.15 | $3,280.80 |