- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.55 / $2,310.39 / $11,997.70
| Professional | | $1,835.55 | $2,310.39 | $11,997.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,270.72 / $3,270.72 / $8,209.01
| Professional | | $3,270.72 | $3,270.72 | $8,209.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,364.50 / $3,000.89 / $8,209.01
| Professional | | $2,364.50 | $3,000.89 | $8,209.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,898.09 / $3,000.89 / $8,209.01
| Professional | | $2,898.09 | $3,000.89 | $8,209.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,836.81 / $3,237.71 / $10,075.64
| Professional | | $2,836.81 | $3,237.71 | $10,075.64 |