- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.25 / $2,225.25 / $4,708.38
| Professional | | $2,225.25 | $2,225.25 | $4,708.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,258.03 / $3,985.51 / $5,976.91
| Professional | | $3,258.03 | $3,985.51 | $5,976.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,157.08 / $4,708.38 / $6,580.80
| Professional | | $3,157.08 | $4,708.38 | $6,580.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,417.87 / $3,804.61 / $5,919.97
| Professional | | $3,417.87 | $3,804.61 | $5,919.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.25 / $2,719.68 / $4,708.38
| Professional | | $2,225.25 | $2,719.68 | $4,708.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,996.15 / $4,455.04 / $5,939.70
| Professional | | $2,996.15 | $4,455.04 | $5,939.70 |