- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.52 / $2,767.19 / $2,767.19
| Professional | | $1,954.52 | $2,767.19 | $2,767.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.63 / $2,371.44 / $3,493.95
| Professional | | $1,921.63 | $2,371.44 | $3,493.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.71 / $2,767.19 / $3,888.83
| Professional | | $2,277.71 | $2,767.19 | $3,888.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.69 / $2,263.80 / $3,522.47
| Professional | | $2,033.69 | $2,263.80 | $3,522.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.52 / $2,767.19 / $2,767.19
| Professional | | $1,954.52 | $2,767.19 | $2,767.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.59 / $2,734.09 / $3,535.46
| Professional | | $1,989.59 | $2,734.09 | $3,535.46 |