- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.98 / $2,915.27 / $2,915.27
| Professional | | $2,037.98 | $2,915.27 | $2,915.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.29 / $2,456.94 / $3,711.79
| Professional | | $2,017.29 | $2,456.94 | $3,711.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,401.61 / $3,066.88 / $6,850.10
| Professional | | $2,401.61 | $3,066.88 | $6,850.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.01 / $2,345.42 / $3,649.47
| Professional | | $2,107.01 | $2,345.42 | $3,649.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.98 / $2,915.27 / $2,915.27
| Professional | | $2,037.98 | $2,915.27 | $2,915.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,596.48 / $2,863.77 / $3,655.01
| Professional | | $2,596.48 | $2,863.77 | $3,655.01 |