- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.80 / $2,805.26 / $2,855.42
| Professional | | $1,845.80 | $2,805.26 | $2,855.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.17 / $2,437.94 / $3,611.77
| Professional | | $1,979.17 | $2,437.94 | $3,611.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.51 / $2,855.42 / $4,000.39
| Professional | | $2,193.51 | $2,855.42 | $4,000.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.71 / $2,327.28 / $3,621.25
| Professional | | $2,090.71 | $2,327.28 | $3,621.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.80 / $2,113.75 / $2,855.42
| Professional | | $1,845.80 | $2,113.75 | $2,855.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.86 / $2,792.61 / $3,632.67
| Professional | | $1,904.86 | $2,792.61 | $3,632.67 |