- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,944.00 / $1,991.30 / $2,973.45
| Professional | | $1,944.00 | $1,991.30 | $2,973.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,671.00 / $6,805.00 / $10,528.00
| Professional | | $5,671.00 | $6,805.00 | $10,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.39 / $3,603.95 / $5,083.67
| Professional | | $2,219.39 | $3,603.95 | $5,083.67 |
- 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
- $2,476.50 / $4,452.22 / $7,400.88
| Professional | | $2,476.50 | $4,452.22 | $7,400.88 |