- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.09 / $1,178.20 / $1,480.13
| Professional | | $1,168.09 | $1,178.20 | $1,480.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.00 / $2,696.00 / $4,079.00
| Professional | | $2,247.00 | $2,696.00 | $4,079.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.86 / $2,002.95 / $3,238.10
| Professional | | $1,312.86 | $2,002.95 | $3,238.10 |
- 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
- $1,655.71 / $2,353.58 / $4,005.28
| Professional | | $1,655.71 | $2,353.58 | $4,005.28 |