- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.87 / $934.21 / $1,179.28
| Professional | | $930.87 | $934.21 | $1,179.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.00 / $2,141.00 / $3,239.00
| Professional | | $1,784.00 | $2,141.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.86 / $1,868.42 / $2,579.67
| Professional | | $1,258.86 | $1,868.42 | $2,579.67 |
- 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
- $1,301.93 / $1,594.20 / $3,090.10
| Professional | | $1,301.93 | $1,594.20 | $3,090.10 |