- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.26 / $2,939.34 / $4,780.82
| Professional | | $2,441.26 | $2,939.34 | $4,780.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.00 / $944.00 / $964.00
| Professional | | $944.00 | $944.00 | $964.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.00 / $913.40 / $1,510.90
| Professional | | $806.00 | $913.40 | $1,510.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,749.51 / $2,800.00 / $13,851.75
| Facility | | $1,749.51 | $2,800.00 | $13,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,701.47 / $3,783.07 / $3,783.07
| Professional | | $3,701.47 | $3,783.07 | $3,783.07 |