- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,273.01 / $2,344.78 / $2,868.07
| Professional | | $2,273.01 | $2,344.78 | $2,868.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,801.00 / $5,761.00 / $9,274.00
| Professional | | $4,801.00 | $5,761.00 | $9,274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.68 / $4,574.39 / $5,818.80
| Professional | | $2,859.68 | $4,574.39 | $5,818.80 |
- 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
- $2,606.44 / $4,728.72 / $7,974.18
| Professional | | $2,606.44 | $4,728.72 | $7,974.18 |