- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.73 / $1,699.59 / $2,174.51
| Professional | | $1,650.73 | $1,699.59 | $2,174.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,212.00 / $3,854.00 / $5,831.00
| Professional | | $3,212.00 | $3,854.00 | $5,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.64 / $3,352.32 / $4,602.68
| Professional | | $2,351.64 | $3,352.32 | $4,602.68 |
- 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
- $2,231.67 / $3,296.79 / $6,593.58
| Professional | | $2,231.67 | $3,296.79 | $6,593.58 |