- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $3,981.07
| Professional | | $1,778.28 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,570.40 / $3,981.07
| Professional | | $1,621.81 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $3,981.07
| Professional | | $2,137.96 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,388.44
| Professional | | $2,137.96 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $5,370.32
| Professional | | $1,905.46 | $2,691.53 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,388.44
| Professional | | $1,905.46 | $2,570.40 | $3,388.44 |