- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.37 / $2,171.37 / $2,171.37
| Professional | | $2,171.37 | $2,171.37 | $2,171.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.80 / $3,333.77 / $5,125.64
| Professional | | $2,628.80 | $3,333.77 | $5,125.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,083.14 / $3,736.60 / $5,793.37
| Professional | | $2,083.14 | $3,736.60 | $5,793.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,349.95 / $4,013.58 / $5,945.83
| Professional | | $3,349.95 | $4,013.58 | $5,945.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.37 / $2,171.37 / $2,171.37
| Professional | | $2,171.37 | $2,171.37 | $2,171.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,647.93 / $3,683.36 / $5,322.24
| Professional | | $2,647.93 | $3,683.36 | $5,322.24 |