- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.54 / $2,911.51 / $2,911.51
| Professional | | $2,155.54 | $2,911.51 | $2,911.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.01 / $2,484.57 / $3,683.23
| Professional | | $2,018.01 | $2,484.57 | $3,683.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.69 / $2,911.51 / $4,078.68
| Professional | | $2,395.69 | $2,911.51 | $4,078.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.71 / $2,371.80 / $3,690.52
| Professional | | $2,130.71 | $2,371.80 | $3,690.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.54 / $2,911.51 / $2,911.51
| Professional | | $2,155.54 | $2,911.51 | $2,911.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.03 / $2,894.08 / $3,702.89
| Professional | | $2,047.03 | $2,894.08 | $3,702.89 |