- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.90 / $1,902.90 / $1,902.90
| Professional | | $1,902.90 | $1,902.90 | $1,902.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,188.55 / $2,574.77 / $3,907.66
| Professional | | $2,188.55 | $2,574.77 | $3,907.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.44 / $3,316.10 / $5,123.95
| Professional | | $1,842.44 | $3,316.10 | $5,123.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,964.13 / $3,551.32 / $5,261.03
| Professional | | $2,964.13 | $3,551.32 | $5,261.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.90 / $1,902.90 / $1,902.90
| Professional | | $1,902.90 | $1,902.90 | $1,902.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.91 / $3,268.94 / $5,261.03
| Professional | | $2,311.91 | $3,268.94 | $5,261.03 |