- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.93 / $1,304.38 / $1,642.53
| Professional | | $1,294.93 | $1,304.38 | $1,642.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.00 / $2,988.00 / $4,519.00
| Professional | | $2,490.00 | $2,988.00 | $4,519.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.62 / $2,608.75 / $3,589.70
| Professional | | $1,782.62 | $2,608.75 | $3,589.70 |
- 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
- $1,492.48 / $2,609.21 / $4,409.60
| Professional | | $1,492.48 | $2,609.21 | $4,409.60 |