- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $10,232.93
| Professional | | $4,265.80 | $5,370.32 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,760.83 / $11,220.18
| Professional | | $4,365.16 | $6,760.83 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $7,943.28
| Facility | | $691.83 | $691.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $6,025.60 / $11,481.54
| Professional | | $1,348.96 | $6,025.60 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,943.28 / $13,803.84
| Professional | | $5,248.07 | $7,943.28 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $14,791.08
| Professional | | $4,365.16 | $6,918.31 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,606.93 / $10,471.29
| Professional | | $4,570.88 | $6,606.93 | $10,471.29 |