- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.26 / $931.26 / $1,442.41
| Professional | | $931.26 | $931.26 | $1,442.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.00 / $2,515.00 / $3,353.00
| Professional | | $1,614.00 | $2,515.00 | $3,353.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.78 / $1,755.64 / $2,793.07
| Professional | | $1,054.78 | $1,755.64 | $2,793.07 |
- 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
- $1,803.90 / $2,577.00 / $4,866.41
| Professional | | $1,803.90 | $2,577.00 | $4,866.41 |