- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.13 / $2,255.75 / $2,790.12
| Professional | | $2,237.13 | $2,255.75 | $2,790.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,396.00 / $5,275.00 / $7,981.00
| Professional | | $4,396.00 | $5,275.00 | $7,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,833.06 / $4,249.59 / $6,197.17
| Professional | | $2,833.06 | $4,249.59 | $6,197.17 |
- 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
- $2,306.92 / $4,271.76 / $7,179.89
| Professional | | $2,306.92 | $4,271.76 | $7,179.89 |