- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.36 / $3,206.03 / $3,206.03
| Professional | | $2,387.36 | $3,206.03 | $3,206.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,222.02 / $2,735.45 / $4,055.41
| Professional | | $2,222.02 | $2,735.45 | $4,055.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.32 / $3,206.03 / $4,489.88
| Professional | | $2,441.32 | $3,206.03 | $4,489.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.85 / $2,611.29 / $4,063.17
| Professional | | $2,345.85 | $2,611.29 | $4,063.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.36 / $3,206.03 / $3,206.03
| Professional | | $2,387.36 | $3,206.03 | $3,206.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.39 / $3,139.61 / $4,063.17
| Professional | | $2,138.39 | $3,139.61 | $4,063.17 |