- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.36 / $1,113.23 / $1,403.51
| Professional | | $1,108.36 | $1,113.23 | $1,403.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.00 / $2,554.00 / $3,863.00
| Professional | | $2,128.00 | $2,554.00 | $3,863.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.73 / $2,226.46 / $3,072.24
| Professional | | $1,517.73 | $2,226.46 | $3,072.24 |
- 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
- $1,249.63 / $2,217.05 / $3,760.88
| Professional | | $1,249.63 | $2,217.05 | $3,760.88 |