- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.30 / $2,769.10 / $2,818.44
| Professional | | $1,821.30 | $2,769.10 | $2,818.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,953.41 / $2,405.98 / $3,564.45
| Professional | | $1,953.41 | $2,405.98 | $3,564.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.33 / $2,818.44 / $3,948.36
| Professional | | $2,233.33 | $2,818.44 | $3,948.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.31 / $2,296.78 / $3,573.79
| Professional | | $2,063.31 | $2,296.78 | $3,573.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.30 / $2,769.10 / $2,818.44
| Professional | | $1,821.30 | $2,769.10 | $2,818.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.05 / $2,800.53 / $3,585.36
| Professional | | $1,981.05 | $2,800.53 | $3,585.36 |