- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.24 / $1,413.20 / $2,056.42
| Professional | | $1,386.24 | $1,413.20 | $2,056.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,962.00 / $4,754.00 / $7,356.00
| Professional | | $3,962.00 | $4,754.00 | $7,356.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.30 / $2,515.61 / $3,497.71
| Professional | | $1,555.30 | $2,515.61 | $3,497.71 |
- 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
- $1,519.91 / $2,814.70 / $5,509.38
| Professional | | $1,519.91 | $2,814.70 | $5,509.38 |