- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $4,168.69
| Professional | | $2,630.27 | $3,311.31 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Professional | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,630.27
| Professional | | $1,698.24 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Professional | | $870.96 | $870.96 | $870.96 |