- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.44 / $837.18 / $1,031.24
| Professional | | $820.44 | $837.18 | $1,031.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.00 / $1,925.00 / $2,911.00
| Professional | | $1,604.00 | $1,925.00 | $2,911.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.22 / $1,564.83 / $2,319.62
| Professional | | $1,043.22 | $1,564.83 | $2,319.62 |
- 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
- $948.34 / $1,652.18 / $2,785.91
| Professional | | $948.34 | $1,652.18 | $2,785.91 |