- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.42 / $1,099.29 / $1,381.18
| Professional | | $1,096.42 | $1,099.29 | $1,381.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.00 / $2,530.00 / $3,828.00
| Professional | | $2,108.00 | $2,530.00 | $3,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.08 / $2,149.62 / $3,044.81
| Professional | | $1,433.08 | $2,149.62 | $3,044.81 |
- 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
- $1,602.97 / $2,155.06 / $3,349.83
| Professional | | $1,602.97 | $2,155.06 | $3,349.83 |