- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.56 / $3,484.42 / $4,808.50
| Professional | | $2,262.56 | $3,484.42 | $4,808.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.46 / $2,645.46 / $2,645.46
| Professional | | $2,645.46 | $2,645.46 | $2,645.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $1,275.00
| Professional | | $1,275.00 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,111.69 / $4,026.89 / $5,491.22
| Professional | | $3,111.69 | $4,026.89 | $5,491.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.34 / $2,568.34 / $5,238.76
| Professional | | $1,826.34 | $2,568.34 | $5,238.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.47 / $1,233.47 / $1,233.47
| Professional | | $1,233.47 | $1,233.47 | $1,233.47 |