- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,966.71 / $4,303.89 / $4,931.31
| Professional | | $3,966.71 | $4,303.89 | $4,931.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $2,675.00 / $2,675.00
| Professional | | $2,675.00 | $2,675.00 | $2,675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,013.70 / $5,978.95 / $13,400.07
| Professional | | $4,013.70 | $5,978.95 | $13,400.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,566.83 / $5,891.21 / $9,372.57
| Professional | | $4,566.83 | $5,891.21 | $9,372.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,433.75 / $4,915.42 / $8,006.01
| Professional | | $3,433.75 | $4,915.42 | $8,006.01 |