- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $3,715.35
| Professional | | $1,148.15 | $2,137.96 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,454.71 / $3,715.35
| Professional | | $1,513.56 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,344.23 / $3,715.35
| Professional | | $2,137.96 | $2,344.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,090.30
| Professional | | $1,995.26 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $5,370.32
| Professional | | $1,949.84 | $2,630.27 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $3,235.94
| Professional | | $1,949.84 | $2,511.89 | $3,235.94 |