- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,398.83 / $4,168.69
| Professional | | $1,288.25 | $2,398.83 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $4,168.69
| Professional | | $1,698.24 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,630.27 / $4,168.69
| Professional | | $2,238.72 | $2,630.27 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,548.13
| Professional | | $2,238.72 | $2,691.53 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $5,754.40
| Professional | | $1,949.84 | $2,951.21 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $3,630.78
| Professional | | $2,041.74 | $2,818.38 | $3,630.78 |