- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.75 / $1,147.94 / $1,703.95
| Professional | | $1,129.75 | $1,147.94 | $1,703.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,282.00 / $3,938.00 / $6,092.00
| Professional | | $3,282.00 | $3,938.00 | $6,092.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.23 / $2,085.27 / $2,921.32
| Professional | | $1,287.23 | $2,085.27 | $2,921.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.19 / $2,554.17 / $4,853.63
| Professional | | $1,311.19 | $2,554.17 | $4,853.63 |