- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.08 / $1,958.42 / $2,909.40
| Professional | | $1,918.08 | $1,958.42 | $2,909.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,581.00 / $6,697.00 / $10,362.00
| Professional | | $5,581.00 | $6,697.00 | $10,362.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.55 / $3,542.29 / $5,026.22
| Professional | | $2,189.55 | $3,542.29 | $5,026.22 |
- 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
- $2,192.69 / $3,987.23 / $8,290.91
| Professional | | $2,192.69 | $3,987.23 | $8,290.91 |