- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.17 / $842.17 / $842.17
| Professional | | $842.17 | $842.17 | $842.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.00 / $1,864.00 / $2,796.00
| Professional | | $1,553.00 | $1,864.00 | $2,796.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.71 / $1,394.38 / $1,885.34
| Professional | | $1,095.71 | $1,394.38 | $1,885.34 |
- 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
- $959.24 / $2,031.83 / $3,232.68
| Professional | | $959.24 | $2,031.83 | $3,232.68 |