- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.21 / $2,021.84 / $3,000.84
| Professional | | $1,973.21 | $2,021.84 | $3,000.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,764.00 / $6,917.00 / $10,702.00
| Professional | | $5,764.00 | $6,917.00 | $10,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.57 / $3,679.54 / $5,226.18
| Professional | | $2,240.57 | $3,679.54 | $5,226.18 |
- 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
- $2,254.85 / $4,086.74 / $8,487.61
| Professional | | $2,254.85 | $4,086.74 | $8,487.61 |