- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.44 / $3,410.74 / $3,484.68
| Professional | | $2,243.44 | $3,410.74 | $3,484.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.46 / $2,950.06 / $4,401.97
| Professional | | $2,403.46 | $2,950.06 | $4,401.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,625.34 / $3,484.68 / $4,864.82
| Professional | | $2,625.34 | $3,484.68 | $4,864.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.89 / $2,816.15 / $4,381.93
| Professional | | $2,529.89 | $2,816.15 | $4,381.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,409.48 / $3,484.67 / $4,113.60
| Professional | | $2,409.48 | $3,484.67 | $4,113.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,309.16 / $3,275.19 / $4,414.80
| Professional | | $2,309.16 | $3,275.19 | $4,414.80 |