- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.94 / $2,450.56 / $2,995.90
| Professional | | $2,374.94 | $2,450.56 | $2,995.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,018.00 / $6,022.00 / $9,692.00
| Professional | | $5,018.00 | $6,022.00 | $9,692.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.47 / $4,176.71 / $6,079.37
| Professional | | $2,784.47 | $4,176.71 | $6,079.37 |
- 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
- $2,580.54 / $4,853.52 / $8,379.79
| Professional | | $2,580.54 | $4,853.52 | $8,379.79 |