- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.58 / $1,961.58 / $3,064.21
| Professional | | $1,961.58 | $1,961.58 | $3,064.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.84 / $2,611.52 / $3,877.24
| Professional | | $2,122.84 | $2,611.52 | $3,877.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.25 / $3,064.21 / $4,288.29
| Professional | | $2,519.25 | $3,064.21 | $4,288.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.57 / $2,492.98 / $3,879.09
| Professional | | $2,239.57 | $2,492.98 | $3,879.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.58 / $2,393.04 / $3,064.21
| Professional | | $1,961.58 | $2,393.04 | $3,064.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.61 / $3,000.71 / $3,889.73
| Professional | | $2,099.61 | $3,000.71 | $3,889.73 |