- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.71 / $1,818.33 / $2,699.71
| Professional | | $1,777.71 | $1,818.33 | $2,699.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,183.00 / $6,220.00 / $9,623.00
| Professional | | $5,183.00 | $6,220.00 | $9,623.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.31 / $3,289.95 / $4,698.66
| Professional | | $2,034.31 | $3,289.95 | $4,698.66 |
- 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
- $2,071.61 / $3,617.71 / $7,692.95
| Professional | | $2,071.61 | $3,617.71 | $7,692.95 |