- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $4,677.35
| Professional | | $1,659.59 | $2,089.30 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,630.27 / $4,265.80
| Professional | | $1,548.82 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $3,981.07
| Professional | | $2,041.74 | $2,630.27 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $4,365.16
| Professional | | $1,905.46 | $2,344.23 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $5,754.40
| Professional | | $1,905.46 | $2,511.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $3,715.35
| Professional | | $1,621.81 | $2,398.83 | $3,715.35 |