- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.86 / $1,291.63 / $1,624.04
| Professional | | $1,280.86 | $1,291.63 | $1,624.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.00 / $2,953.00 / $4,469.00
| Professional | | $2,461.00 | $2,953.00 | $4,469.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.26 / $2,583.25 / $3,549.69
| Professional | | $1,762.26 | $2,583.25 | $3,549.69 |
- 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
- $1,462.32 / $2,572.98 / $4,354.99
| Professional | | $1,462.32 | $2,572.98 | $4,354.99 |