- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.68 / $1,802.44 / $2,667.76
| Professional | | $1,755.68 | $1,802.44 | $2,667.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,148.00 / $6,178.00 / $9,558.00
| Professional | | $5,148.00 | $6,178.00 | $9,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.85 / $3,265.71 / $4,638.34
| Professional | | $2,023.85 | $3,265.71 | $4,638.34 |
- 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
- $2,058.88 / $3,589.19 / $7,579.44
| Professional | | $2,058.88 | $3,589.19 | $7,579.44 |