- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,630.27 / $4,570.88
| Professional | | $1,380.38 | $2,630.27 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $4,570.88
| Professional | | $1,862.09 | $3,019.95 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $4,570.88
| Professional | | $2,238.72 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $3,890.45
| Professional | | $2,454.71 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $6,309.57
| Professional | | $2,398.83 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $3,890.45
| Professional | | $2,089.30 | $3,019.95 | $3,890.45 |