- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.51 / $2,312.86 / $3,405.09
| Professional | | $2,306.51 | $2,312.86 | $3,405.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,632.00 / $7,958.00 / $12,313.00
| Professional | | $6,632.00 | $7,958.00 | $12,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.31 / $4,213.08 / $6,044.47
| Professional | | $2,610.31 | $4,213.08 | $6,044.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,758.37 / $4,713.55 / $9,975.23
| Professional | | $2,758.37 | $4,713.55 | $9,975.23 |