- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $5,888.44
| Professional | | $1,995.26 | $2,511.89 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $4,677.35
| Professional | | $1,949.84 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $4,897.79
| Professional | | $2,454.71 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $5,370.32
| Professional | | $2,398.83 | $2,951.21 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $6,025.60
| Professional | | $2,041.74 | $3,019.95 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $4,786.30
| Professional | | $1,949.84 | $2,818.38 | $4,786.30 |