- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.01 / $3,448.52 / $3,506.96
| Professional | | $2,165.01 | $3,448.52 | $3,506.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.75 / $2,995.82 / $4,430.57
| Professional | | $2,432.75 | $2,995.82 | $4,430.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,887.77 / $3,506.96 / $4,917.83
| Professional | | $2,887.77 | $3,506.96 | $4,917.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,569.14 / $2,859.84 / $4,449.91
| Professional | | $2,569.14 | $2,859.84 | $4,449.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.01 / $3,448.52 / $3,506.96
| Professional | | $2,165.01 | $3,448.52 | $3,506.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,462.76 / $3,481.60 / $4,449.91
| Professional | | $2,462.76 | $3,481.60 | $4,449.91 |