- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.89 / $2,309.89 / $2,851.63
| Professional | | $2,285.89 | $2,309.89 | $2,851.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,501.00 / $5,401.00 / $8,171.00
| Professional | | $4,501.00 | $5,401.00 | $8,171.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.84 / $4,006.26 / $6,332.57
| Professional | | $2,670.84 | $4,006.26 | $6,332.57 |
- 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
- $3,238.88 / $4,666.05 / $7,252.92
| Professional | | $3,238.88 | $4,666.05 | $7,252.92 |