- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.82 / $3,330.32 / $3,330.32
| Professional | | $2,529.82 | $3,330.32 | $3,330.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.32 / $2,742.36 / $4,243.66
| Professional | | $2,293.32 | $2,742.36 | $4,243.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,728.44 / $3,330.32 / $4,605.02
| Professional | | $2,728.44 | $3,330.32 | $4,605.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.78 / $2,617.88 / $4,073.42
| Professional | | $2,351.78 | $2,617.88 | $4,073.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.82 / $3,330.32 / $3,330.32
| Professional | | $2,529.82 | $3,330.32 | $3,330.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.78 / $3,209.69 / $3,873.77
| Professional | | $2,351.78 | $3,209.69 | $3,873.77 |