- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.08 / $1,196.47 / $1,506.78
| Professional | | $1,188.08 | $1,196.47 | $1,506.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.00 / $2,740.00 / $4,145.00
| Professional | | $2,283.00 | $2,740.00 | $4,145.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.00 / $2,392.94 / $3,295.02
| Professional | | $1,628.00 | $2,392.94 | $3,295.02 |
- 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
- $1,364.73 / $2,384.23 / $4,053.41
| Professional | | $1,364.73 | $2,384.23 | $4,053.41 |