- 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
- $1,700.00 / $1,700.00 / $1,700.00
| Professional | | $1,700.00 | $1,700.00 | $1,700.00 |
- 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
- $1,788.22 / $2,435.12 / $4,919.55
| Professional | | $1,788.22 | $2,435.12 | $4,919.55 |
- 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 |