- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.87 / $5,810.63 / $8,223.96
| Professional | | $1,755.87 | $5,810.63 | $8,223.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.58 / $1,268.58 / $4,514.60
| Professional | | $1,268.58 | $1,268.58 | $4,514.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.79 / $3,094.13 / $8,400.15
| Professional | | $1,121.79 | $3,094.13 | $8,400.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.80 / $3,973.20 / $9,805.31
| Professional | | $1,549.80 | $3,973.20 | $9,805.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.52 / $3,081.51 / $10,508.55
| Professional | | $849.52 | $3,081.51 | $10,508.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,611.68 / $5,417.52 / $10,805.03
| Professional | | $3,611.68 | $5,417.52 | $10,805.03 |