- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.17 / $1,515.66 / $1,906.36
| Professional | | $1,502.17 | $1,515.66 | $1,906.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,889.00 / $3,467.00 / $5,245.00
| Professional | | $2,889.00 | $3,467.00 | $5,245.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.02 / $3,031.33 / $4,162.39
| Professional | | $2,074.02 | $3,031.33 | $4,162.39 |
- 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
- $1,630.20 / $3,040.35 / $4,725.93
| Professional | | $1,630.20 | $3,040.35 | $4,725.93 |