- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.50 / $1,176.18 / $1,484.83
| Professional | | $1,170.50 | $1,176.18 | $1,484.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.00 / $2,699.00 / $4,084.00
| Professional | | $2,249.00 | $2,699.00 | $4,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.59 / $2,352.36 / $3,240.40
| Professional | | $1,614.59 | $2,352.36 | $3,240.40 |
- 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
- $1,360.94 / $2,366.10 / $4,049.49
| Professional | | $1,360.94 | $2,366.10 | $4,049.49 |