- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $3,801.89
| Professional | | $1,148.15 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,454.71 / $3,715.35
| Professional | | $1,548.82 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,344.23 / $3,715.35
| Professional | | $2,041.74 | $2,344.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $3,162.28
| Professional | | $2,041.74 | $2,454.71 | $3,162.28 |
- 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
- $1,819.70 / $2,454.71 / $3,235.94
| Professional | | $1,819.70 | $2,454.71 | $3,235.94 |