- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.14 / $1,815.58 / $2,710.06
| Professional | | $1,633.14 | $1,815.58 | $2,710.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,188.00 / $6,226.00 / $9,632.00
| Professional | | $5,188.00 | $6,226.00 | $9,632.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.86 / $3,304.77 / $4,378.88
| Professional | | $2,028.86 | $3,304.77 | $4,378.88 |
- 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
- $1,989.93 / $3,448.80 / $6,438.88
| Professional | | $1,989.93 | $3,448.80 | $6,438.88 |