- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.13 / $3,804.60 / $3,804.60
| Professional | | $2,943.13 | $3,804.60 | $3,804.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.55 / $3,224.25 / $4,801.05
| Professional | | $2,632.55 | $3,224.25 | $4,801.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.44 / $3,373.89 / $5,305.52
| Professional | | $3,134.44 | $3,373.89 | $5,305.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.03 / $3,077.90 / $4,789.21
| Professional | | $2,765.03 | $3,077.90 | $4,789.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.13 / $3,804.60 / $3,804.60
| Professional | | $2,943.13 | $3,804.60 | $3,804.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,821.52 / $3,564.20 / $4,301.62
| Professional | | $2,821.52 | $3,564.20 | $4,301.62 |