- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $6,760.83
| Professional | | $2,344.23 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,981.07 / $5,888.44
| Professional | | $2,454.71 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $6,025.60
| Professional | | $2,754.23 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $6,918.31
| Professional | | $3,019.95 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,630.78 / $7,413.10
| Professional | | $2,511.89 | $3,630.78 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $5,370.32
| Professional | | $2,344.23 | $3,311.31 | $5,370.32 |