- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.75 / $2,719.50 / $2,756.25
| Professional | | $2,388.75 | $2,719.50 | $2,756.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.00 / $3,381.00 / $3,854.34
| Professional | | $2,940.00 | $3,381.00 | $3,854.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.75 / $1,947.75 / $1,947.75
| Professional | | $1,947.75 | $1,947.75 | $1,947.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,675.00 / $4,226.25 / $5,512.50
| Professional | | $3,675.00 | $4,226.25 | $5,512.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $1,653.75 / $2,938.31
| Professional | | $1,543.50 | $1,653.75 | $2,938.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.50 / $1,837.50 / $1,837.50
| Professional | | $1,837.50 | $1,837.50 | $1,837.50 |