- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.06 / $2,301.51 / $11,471.70
| Professional | | $1,874.06 | $2,301.51 | $11,471.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,813.58 / $2,813.58 / $7,687.00
| Professional | | $2,813.58 | $2,813.58 | $7,687.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.37 / $3,607.96 / $7,687.00
| Professional | | $1,832.37 | $3,607.96 | $7,687.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,364.67 / $3,602.78 / $7,687.00
| Professional | | $2,364.67 | $3,602.78 | $7,687.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,433.11 / $3,096.69 / $9,002.29
| Professional | | $2,433.11 | $3,096.69 | $9,002.29 |