- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.24 / $1,427.78 / $1,488.25
| Professional | | $1,177.24 | $1,427.78 | $1,488.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.82 / $1,449.13 / $5,000.00
| Professional | | $1,280.82 | $1,449.13 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.75 / $2,553.03 / $3,948.44
| Professional | | $1,291.75 | $2,553.03 | $3,948.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.52 / $3,304.42 / $3,304.42
| Professional | | $2,603.52 | $3,304.42 | $3,304.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.54 / $2,203.63 / $4,000.76
| Professional | | $1,299.54 | $2,203.63 | $4,000.76 |