- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $6,760.83
| Professional | | $2,238.72 | $2,818.38 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,548.13 / $5,248.07
| Professional | | $2,290.87 | $3,548.13 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,548.13 / $5,370.32
| Professional | | $2,754.23 | $3,548.13 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $6,309.57
| Professional | | $2,818.38 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,388.44 / $7,079.46
| Professional | | $2,290.87 | $3,388.44 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $5,011.87
| Professional | | $2,137.96 | $3,235.94 | $5,011.87 |