- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.19 / $3,000.84 / $5,851.63
| Professional | | $1,117.19 | $3,000.84 | $5,851.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.41 / $3,313.19 / $3,313.19
| Professional | | $3,045.41 | $3,313.19 | $3,313.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.50 / $3,000.84 / $4,379.49
| Professional | | $2,325.50 | $3,000.84 | $4,379.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,358.81 / $2,625.71 / $4,085.60
| Professional | | $2,358.81 | $2,625.71 | $4,085.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.19 / $3,000.84 / $5,851.63
| Professional | | $1,117.19 | $3,000.84 | $5,851.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,479.90 / $4,017.63 / $5,309.24
| Professional | | $2,479.90 | $4,017.63 | $5,309.24 |