- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.22 / $2,608.12 / $2,803.97
| Professional | | $2,001.22 | $2,608.12 | $2,803.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,846.59 / $7,846.59 / $7,846.59
| Professional | | $7,846.59 | $7,846.59 | $7,846.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,402.75 / $3,793.36 / $4,997.08
| Professional | | $2,402.75 | $3,793.36 | $4,997.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.42 / $3,310.61 / $4,997.08
| Professional | | $2,321.42 | $3,310.61 | $4,997.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.13 / $3,087.48 / $9,124.11
| Professional | | $2,578.13 | $3,087.48 | $9,124.11 |