- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.30 / $3,077.48 / $3,077.48
| Professional | | $2,262.30 | $3,077.48 | $3,077.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.96 / $2,616.69 / $3,894.14
| Professional | | $2,130.96 | $2,616.69 | $3,894.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.78 / $3,077.48 / $4,302.56
| Professional | | $2,255.78 | $3,077.48 | $4,302.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.02 / $2,497.92 / $3,886.78
| Professional | | $2,244.02 | $2,497.92 | $3,886.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.30 / $3,077.48 / $3,077.48
| Professional | | $2,262.30 | $3,077.48 | $3,077.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.42 / $2,913.54 / $3,896.89
| Professional | | $2,050.42 | $2,913.54 | $3,896.89 |