- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.21 / $2,853.79 / $2,853.79
| Professional | | $2,109.21 | $2,853.79 | $2,853.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,791.96 / $3,126.61 / $4,383.60
| Professional | | $2,791.96 | $3,126.61 | $4,383.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,525.16 / $3,508.76 / $4,898.32
| Professional | | $2,525.16 | $3,508.76 | $4,898.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,558.40 / $3,295.01 / $5,054.72
| Professional | | $2,558.40 | $3,295.01 | $5,054.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.21 / $2,853.79 / $2,853.79
| Professional | | $2,109.21 | $2,853.79 | $2,853.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.46 / $3,431.76 / $4,445.49
| Professional | | $2,324.46 | $3,431.76 | $4,445.49 |