- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.23 / $801.37 / $996.91
| Professional | | $780.23 | $801.37 | $996.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.00 / $1,818.00 / $2,750.00
| Professional | | $1,515.00 | $1,818.00 | $2,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.16 / $1,590.48 / $2,166.17
| Professional | | $1,104.16 | $1,590.48 | $2,166.17 |
- 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
- $1,006.14 / $1,631.97 / $3,065.39
| Professional | | $1,006.14 | $1,631.97 | $3,065.39 |