- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.82 / $3,182.62 / $3,229.22
| Professional | | $2,058.82 | $3,182.62 | $3,229.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.03 / $2,760.92 / $4,077.75
| Professional | | $2,240.03 | $2,760.92 | $4,077.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,658.55 / $3,229.22 / $4,530.16
| Professional | | $2,658.55 | $3,229.22 | $4,530.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.69 / $2,635.61 / $4,101.01
| Professional | | $2,367.69 | $2,635.61 | $4,101.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.82 / $2,357.71 / $3,229.22
| Professional | | $2,058.82 | $2,357.71 | $3,229.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.92 / $3,156.36 / $4,101.01
| Professional | | $2,240.92 | $3,156.36 | $4,101.01 |