- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.99 / $2,024.75 / $3,024.37
| Professional | | $1,870.99 | $2,024.75 | $3,024.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,755.00 / $6,906.00 / $10,685.00
| Professional | | $5,755.00 | $6,906.00 | $10,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.69 / $3,652.37 / $4,960.57
| Professional | | $2,254.69 | $3,652.37 | $4,960.57 |
- 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
- $2,275.35 / $4,030.62 / $7,832.87
| Professional | | $2,275.35 | $4,030.62 | $7,832.87 |