- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.81 / $1,384.15 / $1,700.74
| Professional | | $1,349.81 | $1,384.15 | $1,700.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.00 / $3,404.00 / $5,482.00
| Professional | | $2,837.00 | $3,404.00 | $5,482.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.65 / $2,697.12 / $3,452.97
| Professional | | $1,675.65 | $2,697.12 | $3,452.97 |
- 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
- $1,510.51 / $2,770.09 / $4,305.84
| Professional | | $1,510.51 | $2,770.09 | $4,305.84 |