- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.92 / $1,196.21 / $1,957.63
| Professional | | $1,047.92 | $1,196.21 | $1,957.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.49 / $1,622.76 / $2,590.87
| Professional | | $1,185.49 | $1,622.76 | $2,590.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.47 / $1,687.88 / $2,534.64
| Professional | | $1,235.47 | $1,687.88 | $2,534.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,976.00 / $9,976.00 / $9,976.00
| Professional | | $9,976.00 | $9,976.00 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.20 / $1,398.76 / $2,501.30
| Professional | | $1,089.20 | $1,398.76 | $2,501.30 |