- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.86 / $2,272.86 / $3,605.47
| Professional | | $2,272.86 | $2,272.86 | $3,605.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,497.35 / $3,071.82 / $4,561.51
| Professional | | $2,497.35 | $3,071.82 | $4,561.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,968.55 / $3,605.47 / $5,043.39
| Professional | | $2,968.55 | $3,605.47 | $5,043.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.31 / $2,932.39 / $4,562.80
| Professional | | $2,634.31 | $2,932.39 | $4,562.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.86 / $2,613.80 / $3,605.47
| Professional | | $2,272.86 | $2,613.80 | $3,605.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,541.44 / $3,596.10 / $4,573.05
| Professional | | $2,541.44 | $3,596.10 | $4,573.05 |