- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,187.76 / $3,890.45
| Professional | | $1,174.90 | $2,187.76 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,511.89 / $3,890.45
| Professional | | $1,584.89 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $3,890.45
| Professional | | $2,089.30 | $2,398.83 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $3,311.31
| Professional | | $2,089.30 | $2,511.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,398.83 / $5,370.32
| Professional | | $1,737.80 | $2,398.83 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $3,311.31
| Professional | | $1,905.46 | $2,511.89 | $3,311.31 |