- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.45 / $1,325.77 / $1,495.26
| Professional | | $1,314.45 | $1,325.77 | $1,495.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.00 / $3,022.00 / $4,571.00
| Professional | | $2,518.00 | $3,022.00 | $4,571.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.44 / $2,465.57 / $3,641.99
| Professional | | $1,640.44 | $2,465.57 | $3,641.99 |
- 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
- $1,721.37 / $2,446.91 / $4,382.31
| Professional | | $1,721.37 | $2,446.91 | $4,382.31 |