- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.53 / $1,776.52 / $2,489.44
| Professional | | $1,510.53 | $1,776.52 | $2,489.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.56 / $2,136.54 / $3,140.47
| Professional | | $1,728.56 | $2,136.54 | $3,140.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.38 / $2,489.44 / $3,500.67
| Professional | | $2,048.38 | $2,489.44 | $3,500.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.24 / $2,039.57 / $3,173.57
| Professional | | $1,832.24 | $2,039.57 | $3,173.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.53 / $1,843.87 / $2,489.44
| Professional | | $1,510.53 | $1,843.87 | $2,489.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.61 / $2,349.98 / $2,836.19
| Professional | | $1,764.61 | $2,349.98 | $2,836.19 |