- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.58 / $2,126.58 / $2,126.58
| Professional | | $2,126.58 | $2,126.58 | $2,126.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.73 / $2,877.33 / $4,366.85
| Professional | | $2,445.73 | $2,877.33 | $4,366.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.31 / $3,706.32 / $5,727.08
| Professional | | $2,059.31 | $3,706.32 | $5,727.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.85 / $3,969.13 / $5,879.98
| Professional | | $3,312.85 | $3,969.13 | $5,879.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.58 / $2,126.58 / $2,126.58
| Professional | | $2,126.58 | $2,126.58 | $2,126.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.69 / $3,653.33 / $5,279.21
| Professional | | $2,583.69 | $3,653.33 | $5,279.21 |