- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,142.36 / $2,901.11 / $2,901.11
| Professional | | $2,142.36 | $2,901.11 | $2,901.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,855.94 / $3,171.59 / $4,484.06
| Professional | | $2,855.94 | $3,171.59 | $4,484.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,559.78 / $3,566.94 / $5,010.12
| Professional | | $2,559.78 | $3,566.94 | $5,010.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,618.39 / $3,372.27 / $5,173.25
| Professional | | $2,618.39 | $3,372.27 | $5,173.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,142.36 / $2,901.11 / $2,901.11
| Professional | | $2,142.36 | $2,901.11 | $2,901.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.67 / $3,717.76 / $4,553.75
| Professional | | $2,662.67 | $3,717.76 | $4,553.75 |