- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.29 / $3,973.74 / $3,973.74
| Professional | | $1,846.29 | $3,973.74 | $3,973.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.61 / $3,317.94 / $4,965.80
| Professional | | $2,723.61 | $3,317.94 | $4,965.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.39 / $3,973.74 / $5,504.64
| Professional | | $1,871.39 | $3,973.74 | $5,504.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.39 / $3,167.34 / $4,928.38
| Professional | | $2,845.39 | $3,167.34 | $4,928.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.95 / $2,550.84 / $3,973.74
| Professional | | $1,459.95 | $2,550.84 | $3,973.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.75 / $3,698.54 / $4,949.68
| Professional | | $2,201.75 | $3,698.54 | $4,949.68 |