- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,089.30 / $3,715.35
| Professional | | $1,122.02 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $3,715.35
| Professional | | $1,513.56 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $3,715.35
| Professional | | $1,949.84 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,162.28
| Professional | | $1,995.26 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $5,011.87
| Professional | | $1,862.09 | $2,570.40 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,162.28
| Professional | | $1,778.28 | $2,398.83 | $3,162.28 |