- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.96 / $2,811.50 / $2,811.50
| Professional | | $2,062.96 | $2,811.50 | $2,811.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,948.11 / $2,393.46 / $3,557.71
| Professional | | $1,948.11 | $2,393.46 | $3,557.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,094.16 / $2,811.50 / $3,934.86
| Professional | | $2,094.16 | $2,811.50 | $3,934.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.57 / $2,284.82 / $3,555.18
| Professional | | $2,052.57 | $2,284.82 | $3,555.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.96 / $2,811.50 / $2,811.50
| Professional | | $2,062.96 | $2,811.50 | $2,811.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.14 / $2,661.21 / $3,566.14
| Professional | | $1,874.14 | $2,661.21 | $3,566.14 |