- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.62 / $2,930.48 / $3,586.92
| Professional | | $2,109.62 | $2,930.48 | $3,586.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.46 / $3,831.19 / $5,403.91
| Professional | | $2,960.46 | $3,831.19 | $5,403.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.44 / $4,174.72 / $6,065.20
| Professional | | $2,861.44 | $4,174.72 | $6,065.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,529.26 / $4,083.35 / $6,264.08
| Professional | | $3,529.26 | $4,083.35 | $6,264.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.62 / $2,699.04 / $3,586.92
| Professional | | $2,109.62 | $2,699.04 | $3,586.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,439.11 / $3,380.37 / $5,582.40
| Professional | | $2,439.11 | $3,380.37 | $5,582.40 |