- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.26 / $2,243.42 / $3,321.81
| Professional | | $2,185.26 | $2,243.42 | $3,321.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,409.00 / $7,691.00 / $11,899.00
| Professional | | $6,409.00 | $7,691.00 | $11,899.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.91 / $4,066.08 / $5,739.20
| Professional | | $2,519.91 | $4,066.08 | $5,739.20 |
- 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
- $2,526.41 / $5,020.59 / $9,480.24
| Professional | | $2,526.41 | $5,020.59 | $9,480.24 |