- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.46 / $2,925.95 / $2,925.95
| Professional | | $2,064.46 | $2,925.95 | $2,925.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.42 / $2,508.32 / $3,693.65
| Professional | | $2,031.42 | $2,508.32 | $3,693.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.36 / $2,925.95 / $4,111.93
| Professional | | $2,407.36 | $2,925.95 | $4,111.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.07 / $2,394.46 / $3,725.80
| Professional | | $2,151.07 | $2,394.46 | $3,725.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.46 / $2,925.95 / $2,925.95
| Professional | | $2,064.46 | $2,925.95 | $2,925.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.06 / $2,888.55 / $3,743.44
| Professional | | $2,096.06 | $2,888.55 | $3,743.44 |