- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.77 / $1,746.28 / $2,703.40
| Professional | | $1,634.77 | $1,746.28 | $2,703.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.40 / $2,308.83 / $3,412.84
| Professional | | $1,875.40 | $2,308.83 | $3,412.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.16 / $2,703.40 / $3,792.29
| Professional | | $2,226.16 | $2,703.40 | $3,792.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.99 / $2,204.03 / $3,429.47
| Professional | | $1,979.99 | $2,204.03 | $3,429.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.77 / $1,879.99 / $2,703.40
| Professional | | $1,634.77 | $1,879.99 | $2,703.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.07 / $2,678.60 / $3,232.79
| Professional | | $1,920.07 | $2,678.60 | $3,232.79 |