- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.75 / $2,064.73 / $2,589.56
| Professional | | $2,036.75 | $2,064.73 | $2,589.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,929.00 / $4,715.00 / $7,133.00
| Professional | | $3,929.00 | $4,715.00 | $7,133.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.33 / $4,129.47 / $5,650.37
| Professional | | $2,845.33 | $4,129.47 | $5,650.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.42 / $3,636.92 / $7,404.79
| Professional | | $2,919.42 | $3,636.92 | $7,404.79 |