- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,558.88 / $4,051.65 / $4,106.39
| Professional | | $3,558.88 | $4,051.65 | $4,106.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.16 / $5,037.18 / $5,742.39
| Professional | | $4,380.16 | $5,037.18 | $5,742.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.86 / $2,901.86 / $2,901.86
| Professional | | $2,901.86 | $2,901.86 | $2,901.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.20 / $6,296.48 / $8,212.79
| Professional | | $5,475.20 | $6,296.48 | $8,212.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $2,518.59 / $4,927.68
| Professional | | $2,299.58 | $2,518.59 | $4,927.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,737.60 / $2,737.60 / $2,737.60
| Professional | | $2,737.60 | $2,737.60 | $2,737.60 |