- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.63 / $2,427.92 / $2,427.92
| Professional | | $1,979.63 | $2,427.92 | $2,427.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.66 / $2,070.91 / $3,088.42
| Professional | | $1,688.66 | $2,070.91 | $3,088.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.59 / $2,427.92 / $3,386.23
| Professional | | $2,010.59 | $2,427.92 | $3,386.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.96 / $1,976.91 / $3,076.07
| Professional | | $1,775.96 | $1,976.91 | $3,076.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.63 / $2,427.92 / $2,427.92
| Professional | | $1,979.63 | $2,427.92 | $2,427.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.75 / $2,609.52 / $3,065.71
| Professional | | $1,848.75 | $2,609.52 | $3,065.71 |