- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.12 / $2,310.86 / $2,310.86
| Professional | | $1,696.12 | $2,310.86 | $2,310.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.36 / $1,983.68 / $2,916.06
| Professional | | $1,605.36 | $1,983.68 | $2,916.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.48 / $2,310.86 / $3,250.79
| Professional | | $1,902.48 | $2,310.86 | $3,250.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.16 / $1,893.65 / $2,946.52
| Professional | | $1,701.16 | $1,893.65 | $2,946.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.21 / $1,696.12 / $2,310.86
| Professional | | $1,598.21 | $1,696.12 | $2,310.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.93 / $2,180.92 / $2,959.77
| Professional | | $1,629.93 | $2,180.92 | $2,959.77 |