- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,073.80 / $7,244.36
| Professional | | $3,162.28 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,248.07 / $8,511.38
| Professional | | $3,311.31 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $16,982.44
| Professional | | $14,125.38 | $14,125.38 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,025.60 / $10,471.29
| Professional | | $4,073.80 | $6,025.60 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $11,481.54
| Professional | | $3,311.31 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $7,943.28
| Professional | | $3,467.37 | $5,011.87 | $7,943.28 |