- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,376.80 / $5,950.62 / $7,129.52
| Professional | | $5,376.80 | $5,950.62 | $7,129.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.00 / $1,794.00 / $2,036.00
| Professional | | $242.00 | $1,794.00 | $2,036.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.00 / $2,077.00 / $3,310.50
| Professional | | $2,077.00 | $2,077.00 | $3,310.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.14 / $3,655.03 / $3,655.03
| Facility | | $1,188.14 | $3,655.03 | $3,655.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,318.94 / $7,747.35 / $7,747.35
| Professional | | $6,318.94 | $7,747.35 | $7,747.35 |