- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.27 / $1,106.16 / $1,367.78
| Professional | | $1,090.27 | $1,106.16 | $1,367.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.00 / $2,524.00 / $3,818.00
| Professional | | $2,103.00 | $2,524.00 | $3,818.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.19 / $2,212.31 / $3,046.32
| Professional | | $1,510.19 | $2,212.31 | $3,046.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.42 / $2,221.04 / $3,857.10
| Professional | | $1,522.42 | $2,221.04 | $3,857.10 |