- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $3,235.94
| Professional | | $1,318.26 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $3,388.44
| Professional | | $1,621.81 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $3,801.89
| Professional | | $2,089.30 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $3,467.37
| Professional | | $2,041.74 | $2,511.89 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $3,235.94
| Professional | | $1,621.81 | $2,137.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $3,630.78
| Professional | | $2,041.74 | $2,511.89 | $3,630.78 |