- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.75 / $1,681.75 / $2,621.68
| Professional | | $1,681.75 | $1,681.75 | $2,621.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.80 / $2,239.31 / $3,314.28
| Professional | | $1,816.80 | $2,239.31 | $3,314.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.14 / $2,621.68 / $3,673.50
| Professional | | $2,157.14 | $2,621.68 | $3,673.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.38 / $2,137.67 / $3,326.21
| Professional | | $1,920.38 | $2,137.67 | $3,326.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.75 / $2,053.01 / $2,621.68
| Professional | | $1,681.75 | $2,053.01 | $2,621.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.81 / $2,480.09 / $2,993.22
| Professional | | $1,748.81 | $2,480.09 | $2,993.22 |