- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.75 / $2,825.00 / $2,825.00
| Professional | | $1,897.75 | $2,825.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.11 / $2,412.89 / $3,566.81
| Professional | | $1,960.11 | $2,412.89 | $3,566.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.23 / $2,825.00 / $3,963.87
| Professional | | $2,326.23 | $2,825.00 | $3,963.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.23 / $2,303.37 / $3,584.04
| Professional | | $2,069.23 | $2,303.37 | $3,584.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.75 / $2,825.00 / $2,825.00
| Professional | | $1,897.75 | $2,825.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.05 / $2,895.48 / $3,598.42
| Professional | | $2,078.05 | $2,895.48 | $3,598.42 |