- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.08 / $1,263.35 / $1,380.01
| Professional | | $1,130.08 | $1,263.35 | $1,380.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.06 / $1,350.25 / $11,208.00
| Professional | | $1,226.06 | $1,350.25 | $11,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.95 / $2,127.73 / $3,698.44
| Professional | | $1,153.95 | $2,127.73 | $3,698.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,498.44 / $3,040.45 / $3,040.45
| Professional | | $2,498.44 | $3,040.45 | $3,040.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.43 / $2,674.75 / $3,681.16
| Professional | | $1,155.43 | $2,674.75 | $3,681.16 |