- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,041.74 / $3,019.95
| Professional | | $1,174.90 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $3,311.31
| Professional | | $1,548.82 | $2,511.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $3,890.45
| Professional | | $2,041.74 | $2,238.72 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $3,467.37
| Professional | | $1,905.46 | $2,344.23 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $4,786.30
| Professional | | $1,584.89 | $2,089.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,801.89
| Professional | | $1,819.70 | $2,454.71 | $3,801.89 |