- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.80 / $1,979.61 / $2,951.54
| Professional | | $1,901.80 | $1,979.61 | $2,951.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,657.00 / $6,788.00 / $10,502.00
| Professional | | $5,657.00 | $6,788.00 | $10,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.89 / $3,601.82 / $4,780.31
| Professional | | $2,213.89 | $3,601.82 | $4,780.31 |
- 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
- $2,229.73 / $4,371.41 / $7,172.10
| Professional | | $2,229.73 | $4,371.41 | $7,172.10 |