- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.89 / $1,900.89 / $2,270.78
| Professional | | $1,900.89 | $1,900.89 | $2,270.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.71 / $2,599.82 / $3,755.37
| Professional | | $2,190.71 | $2,599.82 | $3,755.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.42 / $2,800.70 / $4,289.68
| Professional | | $2,378.42 | $2,800.70 | $4,289.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.33 / $2,808.07 / $4,307.74
| Professional | | $2,180.33 | $2,808.07 | $4,307.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.89 / $1,900.89 / $2,270.78
| Professional | | $1,900.89 | $1,900.89 | $2,270.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.26 / $2,814.23 / $3,931.00
| Professional | | $2,017.26 | $2,814.23 | $3,931.00 |