- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.52 / $1,306.52 / $2,289.67
| Professional | | $1,306.52 | $1,306.52 | $2,289.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.48 / $1,958.21 / $2,889.93
| Professional | | $1,589.48 | $1,958.21 | $2,889.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.17 / $2,289.67 / $3,216.28
| Professional | | $1,886.17 | $2,289.67 | $3,216.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.31 / $1,869.33 / $2,908.68
| Professional | | $1,679.31 | $1,869.33 | $2,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.52 / $1,576.18 / $2,289.67
| Professional | | $1,306.52 | $1,576.18 | $2,289.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.46 / $2,263.00 / $2,921.57
| Professional | | $1,626.46 | $2,263.00 | $2,921.57 |