- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.47 / $904.72 / $1,140.33
| Professional | | $904.47 | $904.72 | $1,140.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.00 / $2,081.00 / $3,149.00
| Professional | | $1,734.00 | $2,081.00 | $3,149.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.64 / $1,862.64 / $1,862.64
| Professional | | $1,862.64 | $1,862.64 | $1,862.64 |
- 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
- $1,038.34 / $1,800.54 / $3,058.90
| Professional | | $1,038.34 | $1,800.54 | $3,058.90 |