- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.90 / $1,777.36 / $2,233.06
| Professional | | $1,757.90 | $1,777.36 | $2,233.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,386.00 / $4,063.00 / $6,146.00
| Professional | | $3,386.00 | $4,063.00 | $6,146.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.84 / $3,554.72 / $4,872.13
| Professional | | $2,435.84 | $3,554.72 | $4,872.13 |
- 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
- $1,944.09 / $3,572.51 / $5,553.12
| Professional | | $1,944.09 | $3,572.51 | $5,553.12 |