- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.87 / $2,650.33 / $2,650.33
| Professional | | $1,940.87 | $2,650.33 | $2,650.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.09 / $2,273.42 / $3,344.94
| Professional | | $1,840.09 | $2,273.42 | $3,344.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.71 / $2,650.33 / $3,725.52
| Professional | | $2,180.71 | $2,650.33 | $3,725.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.63 / $2,170.23 / $3,376.88
| Professional | | $1,949.63 | $2,170.23 | $3,376.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.87 / $2,650.33 / $2,650.33
| Professional | | $1,940.87 | $2,650.33 | $2,650.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.14 / $2,503.05 / $3,236.70
| Professional | | $1,863.14 | $2,503.05 | $3,236.70 |