- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,725.42 / $2,763.15 / $3,465.08
| Professional | | $2,725.42 | $2,763.15 | $3,465.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,258.00 / $6,310.00 / $9,546.00
| Professional | | $5,258.00 | $6,310.00 | $9,546.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.70 / $4,697.35 / $7,562.25
| Professional | | $2,852.70 | $4,697.35 | $7,562.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.04 / $5,545.76 / $8,916.68
| Professional | | $2,926.04 | $5,545.76 | $8,916.68 |