- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.16 / $1,832.16 / $2,205.71
| Professional | | $1,832.16 | $1,832.16 | $2,205.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.38 / $2,490.21 / $3,597.04
| Professional | | $2,128.38 | $2,490.21 | $3,597.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.48 / $2,685.67 / $4,099.85
| Professional | | $2,305.48 | $2,685.67 | $4,099.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.08 / $2,693.14 / $4,131.42
| Professional | | $2,091.08 | $2,693.14 | $4,131.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.16 / $1,832.16 / $2,205.71
| Professional | | $1,832.16 | $1,832.16 | $2,205.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.18 / $2,713.11 / $3,759.88
| Professional | | $1,965.18 | $2,713.11 | $3,759.88 |