- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.14 / $1,653.30 / $2,075.96
| Professional | | $1,635.14 | $1,653.30 | $2,075.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,150.00 / $3,780.00 / $5,718.00
| Professional | | $3,150.00 | $3,780.00 | $5,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.51 / $3,306.61 / $4,533.43
| Professional | | $2,263.51 | $3,306.61 | $4,533.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.06 / $3,320.35 / $5,710.91
| Professional | | $1,863.06 | $3,320.35 | $5,710.91 |