- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.36 / $2,310.34 / $2,857.10
| Professional | | $2,290.36 | $2,310.34 | $2,857.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,504.00 / $5,405.00 / $8,177.00
| Professional | | $4,504.00 | $5,405.00 | $8,177.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,380.16 / $3,927.58 / $6,347.54
| Professional | | $2,380.16 | $3,927.58 | $6,347.54 |
- 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
- $3,193.62 / $4,141.62 / $7,232.37
| Professional | | $3,193.62 | $4,141.62 | $7,232.37 |