- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.88 / $5,384.25 / $5,544.98
| Professional | | $3,454.88 | $5,384.25 | $5,544.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,476.04 / $4,685.35 / $5,625.34
| Professional | | $3,476.04 | $4,685.35 | $5,625.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $10,638.75
| Professional | | $648.63 | $3,087.00 | $10,638.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.75 / $917.75 / $917.75
| Professional | | $917.75 | $917.75 | $917.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.73 / $2,594.52 / $4,324.20
| Professional | | $1,758.73 | $2,594.52 | $4,324.20 |