- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.63 / $1,130.89 / $1,426.08
| Professional | | $1,125.63 | $1,130.89 | $1,426.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.00 / $2,593.00 / $3,924.00
| Professional | | $2,161.00 | $2,593.00 | $3,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.58 / $2,261.79 / $3,120.44
| Professional | | $1,542.58 | $2,261.79 | $3,120.44 |
- 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
- $1,213.61 / $2,254.66 / $3,803.79
| Professional | | $1,213.61 | $2,254.66 | $3,803.79 |