- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.32 / $1,358.69 / $1,462.69
| Professional | | $1,121.32 | $1,358.69 | $1,462.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.04 / $1,347.49 / $6,500.00
| Professional | | $1,226.04 | $1,347.49 | $6,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.72 / $2,503.46 / $3,861.08
| Professional | | $1,235.72 | $2,503.46 | $3,861.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.17 / $3,268.87 / $3,268.87
| Professional | | $2,492.17 | $3,268.87 | $3,268.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.58 / $2,174.77 / $3,957.71
| Professional | | $1,241.58 | $2,174.77 | $3,957.71 |