- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,187.76 / $3,801.89
| Professional | | $1,148.15 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,511.89 / $3,801.89
| Professional | | $1,548.82 | $2,511.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,801.89
| Professional | | $2,041.74 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $3,235.94
| Professional | | $2,089.30 | $2,511.89 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $5,128.61
| Professional | | $1,949.84 | $2,630.27 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $3,388.44
| Professional | | $1,862.09 | $2,570.40 | $3,388.44 |