- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.40 / $886.40 / $1,115.05
| Professional | | $876.40 | $886.40 | $1,115.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.00 / $2,026.00 / $3,064.00
| Professional | | $1,688.00 | $2,026.00 | $3,064.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.05 / $1,772.80 / $2,433.17
| Professional | | $1,205.05 | $1,772.80 | $2,433.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.60 / $1,786.10 / $3,081.00
| Professional | | $1,243.60 | $1,786.10 | $3,081.00 |