- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.92 / $1,133.95 / $1,430.38
| Professional | | $1,128.92 | $1,133.95 | $1,430.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.00 / $2,602.00 / $3,935.00
| Professional | | $2,168.00 | $2,602.00 | $3,935.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.26 / $2,267.91 / $3,128.69
| Professional | | $1,547.26 | $2,267.91 | $3,128.69 |
- 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
- $1,239.68 / $2,261.63 / $3,729.68
| Professional | | $1,239.68 | $2,261.63 | $3,729.68 |