- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.96 / $1,442.40 / $2,284.31
| Professional | | $1,078.96 | $1,442.40 | $2,284.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.05 / $1,958.95 / $3,029.95
| Professional | | $1,365.05 | $1,958.95 | $3,029.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.00 / $1,983.22 / $3,202.07
| Professional | | $1,365.00 | $1,983.22 | $3,202.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,716.32 / $10,873.20 / $12,352.05
| Professional | | $8,716.32 | $10,873.20 | $12,352.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.18 / $1,887.78 / $3,295.56
| Professional | | $1,337.18 | $1,887.78 | $3,295.56 |