- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $8,912.51
| Professional | | $3,311.31 | $5,888.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $6,918.31
| Professional | | $4,677.35 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,495.41 / $10,000.00
| Professional | | $4,897.79 | $5,495.41 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,128.61 / $10,232.93
| Professional | | $3,235.94 | $5,128.61 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,623.41 / $7,413.10
| Professional | | $3,981.07 | $5,623.41 | $7,413.10 |