- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.58 / $2,988.70 / $2,988.70
| Professional | | $2,175.58 | $2,988.70 | $2,988.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.30 / $2,550.64 / $3,780.52
| Professional | | $2,071.30 | $2,550.64 | $3,780.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.02 / $2,988.70 / $4,186.24
| Professional | | $2,460.02 | $2,988.70 | $4,186.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.36 / $2,434.87 / $3,788.66
| Professional | | $2,187.36 | $2,434.87 | $3,788.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.58 / $2,988.70 / $2,988.70
| Professional | | $2,175.58 | $2,988.70 | $2,988.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.96 / $2,988.56 / $3,413.90
| Professional | | $2,118.96 | $2,988.56 | $3,413.90 |