- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.48 / $2,814.85 / $2,814.85
| Professional | | $2,181.48 | $2,814.85 | $2,814.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.70 / $2,400.37 / $3,582.15
| Professional | | $1,958.70 | $2,400.37 | $3,582.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,364.46 / $2,814.85 / $3,925.90
| Professional | | $2,364.46 | $2,814.85 | $3,925.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.50 / $2,291.42 / $3,565.45
| Professional | | $2,058.50 | $2,291.42 | $3,565.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.48 / $2,814.85 / $2,814.85
| Professional | | $2,181.48 | $2,814.85 | $2,814.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.98 / $2,704.09 / $3,263.56
| Professional | | $2,100.98 | $2,704.09 | $3,263.56 |