- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $4,168.69
| Professional | | $1,258.93 | $2,344.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,691.53 / $4,073.80
| Professional | | $1,380.38 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $4,073.80
| Professional | | $2,238.72 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,548.13
| Professional | | $2,238.72 | $2,691.53 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $5,754.40
| Professional | | $1,905.46 | $2,818.38 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $3,548.13
| Professional | | $1,949.84 | $2,754.23 | $3,548.13 |