- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $3,548.13
| Professional | | $1,096.48 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $3,548.13
| Professional | | $1,445.44 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $3,548.13
| Professional | | $1,949.84 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $3,019.95
| Professional | | $1,949.84 | $2,290.87 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $4,786.30
| Professional | | $1,819.70 | $2,454.71 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,019.95
| Professional | | $1,737.80 | $2,344.23 | $3,019.95 |