- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.42 / $3,002.96 / $14,968.40
| Professional | | $2,769.42 | $3,002.96 | $14,968.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,693.94 / $3,693.94 / $10,028.27
| Professional | | $3,693.94 | $3,693.94 | $10,028.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,479.48 / $4,669.08 / $10,028.27
| Professional | | $2,479.48 | $4,669.08 | $10,028.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.01 / $4,656.27 / $10,028.27
| Professional | | $3,101.01 | $4,656.27 | $10,028.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,402.08 / $4,042.81 / $12,308.58
| Professional | | $3,402.08 | $4,042.81 | $12,308.58 |