- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.31 / $1,050.47 / $1,324.45
| Professional | | $1,045.31 | $1,050.47 | $1,324.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.00 / $2,407.00 / $3,642.00
| Professional | | $2,006.00 | $2,407.00 | $3,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.59 / $1,785.80 / $2,898.34
| Professional | | $1,151.59 | $1,785.80 | $2,898.34 |
- 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
- $1,188.51 / $2,087.51 / $3,385.19
| Professional | | $1,188.51 | $2,087.51 | $3,385.19 |