- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.08 / $4,091.55 / $4,091.55
| Professional | | $2,195.08 | $4,091.55 | $4,091.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,819.62 / $3,482.03 / $5,175.22
| Professional | | $2,819.62 | $3,482.03 | $5,175.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.23 / $4,091.55 / $5,692.69
| Professional | | $2,384.23 | $4,091.55 | $5,692.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.10 / $3,323.98 / $5,172.10
| Professional | | $2,986.10 | $3,323.98 | $5,172.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.76 / $2,825.45 / $4,091.55
| Professional | | $2,066.76 | $2,825.45 | $4,091.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.96 / $3,868.15 / $4,668.46
| Professional | | $2,359.96 | $3,868.15 | $4,668.46 |