- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,691.53 / $4,677.35
| Professional | | $1,412.54 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $4,677.35
| Professional | | $1,905.46 | $3,019.95 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $4,570.88
| Professional | | $2,398.83 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $3,890.45
| Professional | | $2,454.71 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $6,309.57
| Professional | | $2,290.87 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $4,073.80
| Professional | | $2,290.87 | $3,235.94 | $4,073.80 |