- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $5,128.61
| Professional | | $1,778.28 | $2,238.72 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $4,265.80
| Professional | | $1,949.84 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $4,265.80
| Professional | | $2,089.30 | $2,691.53 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $5,495.41
| Professional | | $2,398.83 | $2,884.03 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,630.27 / $5,888.44
| Professional | | $1,778.28 | $2,630.27 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,265.80
| Professional | | $1,698.24 | $2,511.89 | $4,265.80 |