- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.83 / $1,226.71 / $1,547.61
| Professional | | $1,222.83 | $1,226.71 | $1,547.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,347.00 / $2,816.00 / $4,260.00
| Professional | | $2,347.00 | $2,816.00 | $4,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.56 / $2,453.41 / $3,389.30
| Professional | | $1,672.56 | $2,453.41 | $3,389.30 |
- 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
- $1,377.05 / $2,446.21 / $4,134.00
| Professional | | $1,377.05 | $2,446.21 | $4,134.00 |