- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.48 / $3,658.01 / $3,658.01
| Professional | | $2,055.48 | $3,658.01 | $3,658.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.42 / $3,118.02 / $4,624.30
| Professional | | $2,534.42 | $3,118.02 | $4,624.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.39 / $3,658.01 / $5,120.18
| Professional | | $2,202.39 | $3,658.01 | $5,120.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.94 / $2,976.50 / $4,631.43
| Professional | | $2,673.94 | $2,976.50 | $4,631.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.48 / $3,658.01 / $3,658.01
| Professional | | $2,055.48 | $3,658.01 | $3,658.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.92 / $3,460.69 / $4,645.47
| Professional | | $2,095.92 | $3,460.69 | $4,645.47 |