- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.46 / $2,617.78 / $2,617.78
| Professional | | $2,029.46 | $2,617.78 | $2,617.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.75 / $2,232.40 / $3,330.72
| Professional | | $1,821.75 | $2,232.40 | $3,330.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.92 / $2,617.78 / $3,652.06
| Professional | | $2,198.92 | $2,617.78 | $3,652.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.45 / $2,131.07 / $3,315.94
| Professional | | $1,914.45 | $2,131.07 | $3,315.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.46 / $2,617.78 / $2,617.78
| Professional | | $2,029.46 | $2,617.78 | $2,617.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.03 / $2,524.54 / $3,046.86
| Professional | | $1,770.03 | $2,524.54 | $3,046.86 |