- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,949.84 / $3,388.44
| Professional | | $1,023.29 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $3,388.44
| Professional | | $1,380.38 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,089.30 / $3,388.44
| Professional | | $1,819.70 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $2,884.03
| Professional | | $1,862.09 | $2,238.72 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $4,570.88
| Professional | | $1,513.56 | $2,344.23 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $2,884.03
| Professional | | $1,659.59 | $2,238.72 | $2,884.03 |