- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.65 / $2,093.62 / $2,624.24
| Professional | | $2,064.65 | $2,093.62 | $2,624.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,983.00 / $4,780.00 / $7,231.00
| Professional | | $3,983.00 | $4,780.00 | $7,231.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.96 / $4,187.24 / $5,724.76
| Professional | | $2,870.96 | $4,187.24 | $5,724.76 |
- 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
- $2,639.46 / $4,217.49 / $7,263.09
| Professional | | $2,639.46 | $4,217.49 | $7,263.09 |