- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,691.53 / $4,677.35
| Professional | | $1,479.11 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,019.95 / $4,570.88
| Professional | | $1,513.56 | $3,019.95 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $4,570.88
| Professional | | $2,691.53 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,801.89
| Professional | | $2,454.71 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,311.31 / $6,606.93
| Professional | | $2,398.83 | $3,311.31 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $4,168.69
| Professional | | $2,398.83 | $3,235.94 | $4,168.69 |