- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,445.93 / $4,077.89 / $18,096.50
| Professional | | $3,445.93 | $4,077.89 | $18,096.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,024.38 / $4,024.38 / $6,750.00
| Professional | | $4,024.38 | $4,024.38 | $6,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,622.53 / $4,673.06 / $7,743.39
| Professional | | $3,622.53 | $4,673.06 | $7,743.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.00 / $661.00 / $661.00
| Facility | | $661.00 | $661.00 | $661.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.05 / $4,222.60 / $7,268.92
| Professional | | $2,723.05 | $4,222.60 | $7,268.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.40 / $4,165.91 / $5,092.67
| Professional | | $2,910.40 | $4,165.91 | $5,092.67 |