- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.97 / $948.97 / $948.97
| Professional | | $948.97 | $948.97 | $948.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,027.00 / $2,432.00 / $3,550.00
| Professional | | $2,027.00 | $2,432.00 | $3,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.64 / $1,891.38 / $2,351.39
| Professional | | $1,256.64 | $1,891.38 | $2,351.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $11,831.32 / $18,767.00
| Facility | | $5,188.00 | $11,831.32 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.45 / $3,284.88 / $4,015.43
| Professional | | $1,440.45 | $3,284.88 | $4,015.43 |