- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,951.21 / $4,365.16
| Professional | | $1,778.28 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,548.13 / $5,370.32
| Professional | | $2,187.76 | $3,548.13 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,388.44 / $5,370.32
| Professional | | $3,162.28 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $4,466.84
| Professional | | $2,884.03 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $4,365.16
| Professional | | $2,818.38 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $4,570.88
| Professional | | $2,818.38 | $3,548.13 | $4,570.88 |