- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.02 / $1,127.54 / $1,420.75
| Professional | | $1,121.02 | $1,127.54 | $1,420.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.00 / $2,582.00 / $3,907.00
| Professional | | $2,152.00 | $2,582.00 | $3,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.07 / $2,255.09 / $3,107.78
| Professional | | $1,530.07 | $2,255.09 | $3,107.78 |
- 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
- $1,275.67 / $2,242.12 / $3,794.70
| Professional | | $1,275.67 | $2,242.12 | $3,794.70 |