- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.71 / $2,919.18 / $2,919.18
| Professional | | $1,768.71 | $2,919.18 | $2,919.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.94 / $2,486.30 / $3,693.88
| Professional | | $2,022.94 | $2,486.30 | $3,693.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.94 / $2,919.18 / $4,085.94
| Professional | | $2,260.94 | $2,919.18 | $4,085.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.19 / $2,373.44 / $3,693.09
| Professional | | $2,132.19 | $2,373.44 | $3,693.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.73 / $1,838.33 / $2,919.18
| Professional | | $1,752.73 | $1,838.33 | $2,919.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.32 / $2,910.76 / $3,702.91
| Professional | | $2,057.32 | $2,910.76 | $3,702.91 |