- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.72 / $2,302.48 / $9,619.29
| Professional | | $1,693.72 | $2,302.48 | $9,619.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.16 / $1,010.16 / $1,010.16
| Professional | | $1,010.16 | $1,010.16 | $1,010.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.65 / $1,691.25 / $2,498.98
| Professional | | $983.65 | $1,691.25 | $2,498.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,883.41 / $9,149.92 / $9,149.92
| Professional | | $8,883.41 | $9,149.92 | $9,149.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.21 / $1,577.16 / $2,450.67
| Professional | | $1,132.21 | $1,577.16 | $2,450.67 |