- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.77 / $1,334.84 / $2,140.69
| Professional | | $1,023.77 | $1,334.84 | $2,140.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.46 / $1,797.54 / $2,766.33
| Professional | | $1,274.46 | $1,797.54 | $2,766.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.69 / $1,805.98 / $2,947.64
| Professional | | $1,242.69 | $1,805.98 | $2,947.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,126.00 / $13,311.20 / $13,311.20
| Professional | | $13,126.00 | $13,311.20 | $13,311.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.26 / $1,676.53 / $3,017.52
| Professional | | $1,232.26 | $1,676.53 | $3,017.52 |