- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.98 / $1,637.41 / $2,056.65
| Professional | | $1,618.98 | $1,637.41 | $2,056.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,117.00 / $3,740.00 / $5,659.00
| Professional | | $3,117.00 | $3,740.00 | $5,659.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.06 / $3,274.82 / $4,489.84
| Professional | | $2,238.06 | $3,274.82 | $4,489.84 |
- 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
- $1,800.06 / $3,272.99 / $5,466.51
| Professional | | $1,800.06 | $3,272.99 | $5,466.51 |