- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.79 / $2,990.37 / $2,990.37
| Professional | | $1,091.79 | $2,990.37 | $2,990.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.79 / $3,084.56 / $3,109.43
| Professional | | $2,837.79 | $3,084.56 | $3,109.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.25 / $2,990.37 / $4,395.93
| Professional | | $2,247.25 | $2,990.37 | $4,395.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.88 / $2,882.93 / $4,485.84
| Professional | | $2,589.88 | $2,882.93 | $4,485.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.79 / $2,990.37 / $2,990.37
| Professional | | $1,091.79 | $2,990.37 | $2,990.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.12 / $4,756.22 / $5,740.28
| Professional | | $2,823.12 | $4,756.22 | $5,740.28 |