- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.37 / $3,896.83 / $3,896.83
| Professional | | $2,904.37 | $3,896.83 | $3,896.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,702.79 / $3,311.90 / $4,950.43
| Professional | | $2,702.79 | $3,311.90 | $4,950.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.17 / $3,896.83 / $5,464.50
| Professional | | $2,974.17 | $3,896.83 | $5,464.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,840.20 / $3,161.57 / $4,919.39
| Professional | | $2,840.20 | $3,161.57 | $4,919.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.37 / $3,896.83 / $3,896.83
| Professional | | $2,904.37 | $3,896.83 | $3,896.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.96 / $3,676.27 / $4,436.88
| Professional | | $2,396.96 | $3,676.27 | $4,436.88 |