- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,137.96 / $3,715.35
| Professional | | $1,122.02 | $2,137.96 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,454.71 / $3,715.35
| Professional | | $1,513.56 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $3,715.35
| Professional | | $1,819.70 | $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
- $1,659.59 / $2,570.40 / $4,570.88
| Professional | | $1,659.59 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $3,162.28
| Professional | | $1,737.80 | $2,454.71 | $3,162.28 |