- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,879.22 / $1,930.66 / $2,857.24
| Professional | | $1,879.22 | $1,930.66 | $2,857.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,516.00 / $6,619.00 / $10,241.00
| Professional | | $5,516.00 | $6,619.00 | $10,241.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.48 / $3,498.30 / $4,997.55
| Professional | | $2,168.48 | $3,498.30 | $4,997.55 |
- 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
- $2,198.92 / $3,725.40 / $7,226.67
| Professional | | $2,198.92 | $3,725.40 | $7,226.67 |