- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.01 / $1,779.01 / $2,993.49
| Professional | | $1,779.01 | $1,779.01 | $2,993.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.65 / $2,561.44 / $3,780.42
| Professional | | $2,077.65 | $2,561.44 | $3,780.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.14 / $2,993.49 / $4,202.24
| Professional | | $2,449.14 | $2,993.49 | $4,202.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.62 / $2,445.17 / $3,804.68
| Professional | | $2,196.62 | $2,445.17 | $3,804.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.01 / $2,084.16 / $2,993.49
| Professional | | $1,779.01 | $2,084.16 | $2,993.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.29 / $2,925.32 / $3,819.06
| Professional | | $2,044.29 | $2,925.32 | $3,819.06 |