- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.30 / $1,962.02 / $6,602.14
| Professional | | $1,106.30 | $1,962.02 | $6,602.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.94 / $1,969.55 / $2,850.00
| Professional | | $1,379.94 | $1,969.55 | $2,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.95 / $882.38 / $1,375.37
| Professional | | $122.95 | $882.38 | $1,375.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.25 / $2,214.85 / $4,116.35
| Professional | | $1,541.25 | $2,214.85 | $4,116.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.70 / $1,656.42 / $2,571.82
| Professional | | $1,307.70 | $1,656.42 | $2,571.82 |