- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.12 / $2,562.84 / $2,562.84
| Professional | | $1,903.12 | $2,562.84 | $2,562.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.21 / $2,187.06 / $3,242.16
| Professional | | $1,776.21 | $2,187.06 | $3,242.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.25 / $2,562.84 / $3,589.95
| Professional | | $2,109.25 | $2,562.84 | $3,589.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.57 / $2,087.79 / $3,248.60
| Professional | | $1,875.57 | $2,087.79 | $3,248.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.12 / $2,562.84 / $2,562.84
| Professional | | $1,903.12 | $2,562.84 | $2,562.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.00 / $2,425.04 / $3,135.83
| Professional | | $1,858.00 | $2,425.04 | $3,135.83 |