- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.44 / $3,019.19 / $3,019.19
| Professional | | $2,134.44 | $3,019.19 | $3,019.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.83 / $2,576.55 / $3,820.59
| Professional | | $2,092.83 | $2,576.55 | $3,820.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.44 / $3,019.19 / $4,229.50
| Professional | | $2,542.44 | $3,019.19 | $4,229.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.58 / $2,459.60 / $3,827.14
| Professional | | $2,209.58 | $2,459.60 | $3,827.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.44 / $3,019.19 / $3,019.19
| Professional | | $2,134.44 | $3,019.19 | $3,019.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.84 / $3,003.41 / $3,624.81
| Professional | | $2,153.84 | $3,003.41 | $3,624.81 |