- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.13 / $1,204.49 / $1,420.46
| Professional | | $1,138.13 | $1,204.49 | $1,420.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.00 / $3,032.00 / $4,882.00
| Professional | | $2,527.00 | $3,032.00 | $4,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.11 / $2,286.92 / $3,080.59
| Professional | | $1,441.11 | $2,286.92 | $3,080.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.20 / $2,308.98 / $4,030.00
| Professional | | $1,239.20 | $2,308.98 | $4,030.00 |