- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.54 / $3,088.92 / $3,159.25
| Professional | | $2,023.54 | $3,088.92 | $3,159.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,188.14 / $2,690.98 / $3,995.54
| Professional | | $2,188.14 | $2,690.98 | $3,995.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,600.57 / $3,159.25 / $4,420.10
| Professional | | $2,600.57 | $3,159.25 | $4,420.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,307.71 / $2,568.83 / $3,997.10
| Professional | | $2,307.71 | $2,568.83 | $3,997.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.54 / $3,088.92 / $3,159.25
| Professional | | $2,023.54 | $3,088.92 | $3,159.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.19 / $3,148.11 / $3,799.44
| Professional | | $2,225.19 | $3,148.11 | $3,799.44 |