- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.92 / $2,529.42 / $3,167.82
| Professional | | $2,488.92 | $2,529.42 | $3,167.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,808.00 / $5,770.00 / $8,729.00
| Professional | | $4,808.00 | $5,770.00 | $8,729.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.32 / $5,058.87 / $6,903.94
| Professional | | $3,473.32 | $5,058.87 | $6,903.94 |
- 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
- $3,591.70 / $5,105.56 / $8,080.79
| Professional | | $3,591.70 | $5,105.56 | $8,080.79 |