- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,052.70 / $4,207.55 / $12,524.40
| Professional | | $4,052.70 | $4,207.55 | $12,524.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.00 / $561.00 / $8,704.00
| Professional | | $280.00 | $561.00 | $8,704.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.57 / $410.33 / $7,204.60
| Professional | | $239.57 | $410.33 | $7,204.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,236.00 / $7,901.59 / $12,566.40
| Professional | | $5,236.00 | $7,901.59 | $12,566.40 |