- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.87 / $2,547.87 / $2,724.00
| Professional | | $2,547.87 | $2,547.87 | $2,724.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.29 / $2,719.73 / $4,225.22
| Professional | | $2,419.29 | $2,719.73 | $4,225.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.03 / $3,044.92 / $4,362.37
| Professional | | $2,000.03 | $3,044.92 | $4,362.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,297.71 / $2,959.26 / $4,539.66
| Professional | | $2,297.71 | $2,959.26 | $4,539.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.87 / $2,547.87 / $2,724.00
| Professional | | $2,547.87 | $2,547.87 | $2,724.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.07 / $2,859.48 / $4,016.54
| Professional | | $2,025.07 | $2,859.48 | $4,016.54 |