- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.45 / $2,111.88 / $2,111.88
| Professional | | $1,589.45 | $2,111.88 | $2,111.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.29 / $2,292.56 / $3,311.54
| Professional | | $2,054.29 | $2,292.56 | $3,311.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.38 / $2,279.13 / $3,780.81
| Professional | | $2,139.38 | $2,279.13 | $3,780.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.34 / $2,489.98 / $3,819.76
| Professional | | $1,933.34 | $2,489.98 | $3,819.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.45 / $2,111.88 / $2,111.88
| Professional | | $1,589.45 | $2,111.88 | $2,111.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.06 / $2,493.63 / $3,724.48
| Professional | | $2,116.06 | $2,493.63 | $3,724.48 |