- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.81 / $1,830.82 / $2,265.79
| Professional | | $1,817.81 | $1,830.82 | $2,265.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.00 / $4,284.00 / $6,481.00
| Professional | | $3,570.00 | $4,284.00 | $6,481.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.98 / $3,555.36 / $5,037.27
| Professional | | $2,411.98 | $3,555.36 | $5,037.27 |
- 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
- $2,024.65 / $3,667.23 / $6,129.50
| Professional | | $2,024.65 | $3,667.23 | $6,129.50 |