- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.53 / $1,806.53 / $2,155.66
| Professional | | $1,806.53 | $1,806.53 | $2,155.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.69 / $2,472.16 / $3,570.98
| Professional | | $2,086.69 | $2,472.16 | $3,570.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.64 / $2,662.36 / $4,080.69
| Professional | | $2,238.64 | $2,662.36 | $4,080.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.94 / $2,669.78 / $4,095.58
| Professional | | $2,072.94 | $2,669.78 | $4,095.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.53 / $1,806.53 / $2,155.66
| Professional | | $1,806.53 | $1,806.53 | $2,155.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.32 / $2,894.22 / $4,095.58
| Professional | | $1,902.32 | $2,894.22 | $4,095.58 |