- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.07 / $1,516.07 / $1,806.49
| Professional | | $1,516.07 | $1,516.07 | $1,806.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.46 / $2,094.23 / $3,032.40
| Professional | | $1,743.46 | $2,094.23 | $3,032.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.02 / $2,252.05 / $3,505.96
| Professional | | $1,958.02 | $2,252.05 | $3,505.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.74 / $2,271.55 / $3,484.68
| Professional | | $1,763.74 | $2,271.55 | $3,484.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.07 / $1,516.07 / $1,806.49
| Professional | | $1,516.07 | $1,516.07 | $1,806.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.31 / $2,197.07 / $3,191.80
| Professional | | $1,963.31 | $2,197.07 | $3,191.80 |