- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.50 / $1,019.21 / $1,513.06
| Professional | | $978.50 | $1,019.21 | $1,513.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,868.00 / $3,442.00 / $5,324.00
| Professional | | $2,868.00 | $3,442.00 | $5,324.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.36 / $1,856.99 / $2,591.01
| Professional | | $1,106.36 | $1,856.99 | $2,591.01 |
- 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
- $1,128.96 / $2,018.25 / $4,194.93
| Professional | | $1,128.96 | $2,018.25 | $4,194.93 |