- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,025.60 / $6,456.54
| Professional | | $5,754.40 | $6,025.60 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,165.95 / $6,165.95
| Professional | | $2,290.87 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.01 / $676.08
| Professional | | $5.01 | $5.01 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,606.93 / $7,413.10
| Professional | | $2,344.23 | $6,606.93 | $7,413.10 |