- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.96 / $2,481.55 / $2,481.55
| Professional | | $1,853.96 | $2,481.55 | $2,481.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,444.08 / $2,718.63 / $3,837.40
| Professional | | $2,444.08 | $2,718.63 | $3,837.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.17 / $3,051.09 / $4,287.04
| Professional | | $2,512.17 | $3,051.09 | $4,287.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.94 / $2,884.86 / $4,425.54
| Professional | | $2,239.94 | $2,884.86 | $4,425.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.96 / $2,481.55 / $2,481.55
| Professional | | $1,853.96 | $2,481.55 | $2,481.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,474.13 / $3,178.62 / $3,898.54
| Professional | | $2,474.13 | $3,178.62 | $3,898.54 |