- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.85 / $2,091.55 / $2,986.57
| Professional | | $2,020.85 | $2,091.55 | $2,986.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,776.00 / $6,931.00 / $10,724.00
| Professional | | $5,776.00 | $6,931.00 | $10,724.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.26 / $3,662.74 / $5,571.03
| Professional | | $2,270.26 | $3,662.74 | $5,571.03 |
- 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
- $2,505.94 / $4,132.99 / $9,324.49
| Professional | | $2,505.94 | $4,132.99 | $9,324.49 |