- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.52 / $2,943.49 / $2,943.49
| Professional | | $2,178.52 | $2,943.49 | $2,943.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.54 / $2,504.44 / $3,724.23
| Professional | | $2,039.54 | $2,504.44 | $3,724.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,424.71 / $2,943.49 / $4,118.20
| Professional | | $2,424.71 | $2,943.49 | $4,118.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.73 / $2,390.76 / $3,720.02
| Professional | | $2,147.73 | $2,390.76 | $3,720.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.94 / $2,178.52 / $2,943.49
| Professional | | $2,025.94 | $2,178.52 | $2,943.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.02 / $2,883.42 / $3,363.99
| Professional | | $1,962.02 | $2,883.42 | $3,363.99 |