- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.57 / $1,727.29 / $1,727.29
| Professional | | $1,726.57 | $1,727.29 | $1,727.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.08 / $2,300.05 / $3,322.35
| Professional | | $2,006.08 | $2,300.05 | $3,322.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.59 / $2,474.83 / $3,736.51
| Professional | | $1,912.59 | $2,474.83 | $3,736.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.67 / $2,494.27 / $3,826.35
| Professional | | $1,936.67 | $2,494.27 | $3,826.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.57 / $1,727.29 / $1,727.29
| Professional | | $1,726.57 | $1,727.29 | $1,727.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.10 / $2,402.29 / $3,451.52
| Professional | | $1,704.10 | $2,402.29 | $3,451.52 |