- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.64 / $2,837.55 / $2,894.16
| Professional | | $1,894.64 | $2,837.55 | $2,894.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.88 / $2,452.62 / $3,656.98
| Professional | | $1,997.88 | $2,452.62 | $3,656.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.84 / $2,894.16 / $4,043.03
| Professional | | $2,273.84 | $2,894.16 | $4,043.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.30 / $2,341.30 / $3,643.06
| Professional | | $2,103.30 | $2,341.30 | $3,643.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.64 / $2,165.81 / $2,894.16
| Professional | | $1,894.64 | $2,165.81 | $2,894.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.07 / $2,740.79 / $3,544.13
| Professional | | $1,934.07 | $2,740.79 | $3,544.13 |