- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $4,265.80
| Professional | | $1,258.93 | $2,398.83 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,754.23 / $4,168.69
| Professional | | $1,737.80 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $4,168.69
| Professional | | $2,290.87 | $2,630.27 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $3,548.13
| Professional | | $2,290.87 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,951.21 / $5,754.40
| Professional | | $2,041.74 | $2,951.21 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $3,715.35
| Professional | | $2,089.30 | $2,884.03 | $3,715.35 |