- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.38 / $2,554.50 / $3,119.87
| Professional | | $1,898.38 | $2,554.50 | $3,119.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.76 / $3,288.05 / $4,612.52
| Professional | | $2,540.76 | $3,288.05 | $4,612.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.89 / $3,579.38 / $5,247.00
| Professional | | $2,458.89 | $3,579.38 | $5,247.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,011.95 / $3,484.83 / $5,345.91
| Professional | | $3,011.95 | $3,484.83 | $5,345.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.38 / $2,558.50 / $3,119.87
| Professional | | $1,898.38 | $2,558.50 | $3,119.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,124.14 / $2,986.71 / $4,804.97
| Professional | | $2,124.14 | $2,986.71 | $4,804.97 |