- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.62 / $1,473.70 / $1,851.75
| Professional | | $1,459.62 | $1,473.70 | $1,851.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,809.00 / $3,371.00 / $5,100.00
| Professional | | $2,809.00 | $3,371.00 | $5,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.75 / $2,947.41 / $4,047.01
| Professional | | $2,014.75 | $2,947.41 | $4,047.01 |
- 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
- $1,680.69 / $2,953.29 / $5,041.39
| Professional | | $1,680.69 | $2,953.29 | $5,041.39 |