- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.33 / $2,064.77 / $2,064.77
| Professional | | $1,561.33 | $2,064.77 | $2,064.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.86 / $2,226.09 / $3,215.53
| Professional | | $1,975.86 | $2,226.09 | $3,215.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.21 / $2,228.75 / $3,697.25
| Professional | | $2,091.21 | $2,228.75 | $3,697.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.90 / $2,406.98 / $3,692.45
| Professional | | $1,868.90 | $2,406.98 | $3,692.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.33 / $2,064.77 / $2,064.77
| Professional | | $1,561.33 | $2,064.77 | $2,064.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.43 / $2,406.98 / $3,379.71
| Professional | | $1,945.43 | $2,406.98 | $3,379.71 |