- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,773.61 / $3,862.11 / $4,858.82
| Professional | | $3,773.61 | $3,862.11 | $4,858.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,294.00 / $8,753.00 / $13,241.00
| Professional | | $7,294.00 | $8,753.00 | $13,241.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,264.41 / $6,565.59 / $10,508.42
| Professional | | $4,264.41 | $6,565.59 | $10,508.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,551.78 / $7,681.32 / $11,939.88
| Professional | | $4,551.78 | $7,681.32 | $11,939.88 |