- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.84 / $1,778.11 / $2,232.96
| Professional | | $1,736.84 | $1,778.11 | $2,232.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,347.00 / $4,016.00 / $6,077.00
| Professional | | $3,347.00 | $4,016.00 | $6,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.15 / $3,556.22 / $4,813.84
| Professional | | $2,435.15 | $3,556.22 | $4,813.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.69 / $3,573.20 / $5,894.20
| Professional | | $2,513.69 | $3,573.20 | $5,894.20 |