- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.90 / $2,035.90 / $2,458.71
| Professional | | $2,035.90 | $2,035.90 | $2,458.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,133.37 / $2,439.44 / $3,601.69
| Professional | | $2,133.37 | $2,439.44 | $3,601.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.57 / $2,498.64 / $3,756.75
| Professional | | $1,832.57 | $2,498.64 | $3,756.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.17 / $2,621.13 / $4,020.95
| Professional | | $2,035.17 | $2,621.13 | $4,020.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.90 / $2,035.90 / $2,458.71
| Professional | | $2,035.90 | $2,035.90 | $2,458.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.89 / $2,717.14 / $3,484.52
| Professional | | $2,058.89 | $2,717.14 | $3,484.52 |