- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.66 / $2,214.65 / $2,777.12
| Professional | | $2,185.66 | $2,214.65 | $2,777.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,215.00 / $5,058.00 / $7,651.00
| Professional | | $4,215.00 | $5,058.00 | $7,651.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,034.03 / $4,429.31 / $6,061.11
| Professional | | $3,034.03 | $4,429.31 | $6,061.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.29 / $4,451.53 / $7,595.88
| Professional | | $2,662.29 | $4,451.53 | $7,595.88 |