- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.44 / $886.44 / $1,110.97
| Professional | | $886.44 | $886.44 | $1,110.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.00 / $2,047.00 / $2,561.00
| Professional | | $1,535.00 | $2,047.00 | $2,561.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.71 / $1,336.05 / $1,939.92
| Professional | | $1,011.71 | $1,336.05 | $1,939.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.64 / $1,851.61 / $3,341.19
| Professional | | $1,256.64 | $1,851.61 | $3,341.19 |