- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.71 / $3,450.64 / $3,450.64
| Professional | | $2,431.71 | $3,450.64 | $3,450.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.69 / $2,933.64 / $4,365.43
| Professional | | $2,389.69 | $2,933.64 | $4,365.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,602.42 / $3,450.64 / $4,823.79
| Professional | | $2,602.42 | $3,450.64 | $4,823.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.82 / $2,800.49 / $4,357.56
| Professional | | $2,515.82 | $2,800.49 | $4,357.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.71 / $3,450.64 / $3,450.64
| Professional | | $2,431.71 | $3,450.64 | $3,450.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.25 / $3,447.67 / $4,367.50
| Professional | | $2,435.25 | $3,447.67 | $4,367.50 |