- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.94 / $2,914.88 / $4,741.04
| Professional | | $2,420.94 | $2,914.88 | $4,741.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.00 / $936.00 / $1,018.00
| Professional | | $936.00 | $936.00 | $1,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.10 / $865.20 / $1,571.70
| Professional | | $726.10 | $865.20 | $1,571.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $8,444.70 / $26,542.00
| Facility | | $1,737.80 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,948.35 / $4,948.35 / $4,948.35
| Professional | | $4,948.35 | $4,948.35 | $4,948.35 |