- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,949.84 / $2,951.21
| Professional | | $1,071.52 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $3,715.35
| Professional | | $1,288.25 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $3,715.35
| Professional | | $2,137.96 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $3,090.30
| Professional | | $1,949.84 | $2,344.23 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $2,951.21
| Professional | | $1,778.28 | $2,344.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,311.31
| Professional | | $1,862.09 | $2,290.87 | $3,311.31 |