- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.83 / $2,808.36 / $2,808.36
| Professional | | $2,161.83 | $2,808.36 | $2,808.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,953.75 / $2,393.89 / $3,573.20
| Professional | | $1,953.75 | $2,393.89 | $3,573.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.42 / $2,808.36 / $3,916.15
| Professional | | $2,334.42 | $2,808.36 | $3,916.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.94 / $2,285.23 / $3,555.83
| Professional | | $2,052.94 | $2,285.23 | $3,555.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.83 / $2,808.36 / $2,808.36
| Professional | | $2,161.83 | $2,808.36 | $2,808.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.54 / $3,045.30 / $3,675.37
| Professional | | $2,152.54 | $3,045.30 | $3,675.37 |