- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.11 / $1,759.48 / $2,186.11
| Professional | | $1,757.11 | $1,759.48 | $2,186.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,435.00 / $4,122.00 / $6,236.00
| Professional | | $3,435.00 | $4,122.00 | $6,236.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.10 / $3,229.66 / $4,866.27
| Professional | | $2,153.10 | $3,229.66 | $4,866.27 |
- 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
- $1,709.25 / $3,500.75 / $5,441.58
| Professional | | $1,709.25 | $3,500.75 | $5,441.58 |