- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.98 / $3,398.82 / $3,398.82
| Professional | | $2,330.98 | $3,398.82 | $3,398.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,356.51 / $2,896.51 / $4,294.63
| Professional | | $2,356.51 | $2,896.51 | $4,294.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.21 / $3,398.82 / $4,761.01
| Professional | | $2,800.21 | $3,398.82 | $4,761.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.96 / $2,765.04 / $4,302.39
| Professional | | $2,483.96 | $2,765.04 | $4,302.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.78 / $2,347.34 / $3,398.82
| Professional | | $2,220.78 | $2,347.34 | $3,398.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.10 / $3,545.39 / $4,316.54
| Professional | | $2,640.10 | $3,545.39 | $4,316.54 |