- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.63 / $1,592.22 / $2,000.21
| Professional | | $1,575.63 | $1,592.22 | $2,000.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,034.00 / $3,641.00 / $5,507.00
| Professional | | $3,034.00 | $3,641.00 | $5,507.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.41 / $3,184.45 / $4,367.58
| Professional | | $2,179.41 | $3,184.45 | $4,367.58 |
- 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
- $2,248.12 / $3,228.79 / $5,309.20
| Professional | | $2,248.12 | $3,228.79 | $5,309.20 |