- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.41 / $1,258.95 / $1,584.58
| Professional | | $1,248.41 | $1,258.95 | $1,584.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,880.00 / $4,357.00
| Professional | | $2,400.00 | $2,880.00 | $4,357.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.30 / $2,517.91 / $3,459.80
| Professional | | $1,717.30 | $2,517.91 | $3,459.80 |
- 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
- $1,372.78 / $2,519.34 / $4,243.18
| Professional | | $1,372.78 | $2,519.34 | $4,243.18 |