- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.98 / $3,250.87 / $3,250.87
| Professional | | $2,330.98 | $3,250.87 | $3,250.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.27 / $2,781.22 / $4,106.06
| Professional | | $2,256.27 | $2,781.22 | $4,106.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.84 / $3,250.87 / $4,562.41
| Professional | | $2,310.84 | $3,250.87 | $4,562.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.10 / $2,654.98 / $4,131.14
| Professional | | $2,385.10 | $2,654.98 | $4,131.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.98 / $3,250.87 / $3,250.87
| Professional | | $2,330.98 | $3,250.87 | $3,250.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.09 / $3,073.07 / $3,973.80
| Professional | | $2,167.09 | $3,073.07 | $3,973.80 |