- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.25 / $1,142.07 / $1,419.51
| Professional | | $1,138.25 | $1,142.07 | $1,419.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.00 / $2,668.00 / $4,034.00
| Professional | | $2,223.00 | $2,668.00 | $4,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.36 / $2,049.54 / $3,161.26
| Professional | | $1,366.36 | $2,049.54 | $3,161.26 |
- 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
- $1,136.41 / $2,065.69 / $3,497.07
| Professional | | $1,136.41 | $2,065.69 | $3,497.07 |