- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.71 / $2,980.88 / $2,980.88
| Professional | | $2,202.71 | $2,980.88 | $2,980.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.17 / $2,551.07 / $3,764.07
| Professional | | $2,069.17 | $2,551.07 | $3,764.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.26 / $2,980.88 / $4,185.47
| Professional | | $2,369.26 | $2,980.88 | $4,185.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.73 / $2,435.28 / $3,789.30
| Professional | | $2,187.73 | $2,435.28 | $3,789.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.71 / $2,980.88 / $2,980.88
| Professional | | $2,202.71 | $2,980.88 | $2,980.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.14 / $2,816.61 / $3,642.17
| Professional | | $1,987.14 | $2,816.61 | $3,642.17 |