- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.82 / $1,545.17 / $1,941.78
| Professional | | $1,530.82 | $1,545.17 | $1,941.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.00 / $3,534.00 / $5,346.00
| Professional | | $2,945.00 | $3,534.00 | $5,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.65 / $3,090.33 / $4,241.68
| Professional | | $2,113.65 | $3,090.33 | $4,241.68 |
- 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
- $1,488.62 / $3,100.26 / $4,829.50
| Professional | | $1,488.62 | $3,100.26 | $4,829.50 |