- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.43 / $856.43 / $856.43
| Professional | | $856.43 | $856.43 | $856.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.00 / $1,897.00 / $2,845.00
| Professional | | $1,581.00 | $1,897.00 | $2,845.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.42 / $1,418.52 / $1,903.51
| Professional | | $1,113.42 | $1,418.52 | $1,903.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $20,822.43 / $26,502.00
| Facility | | $6,934.00 | $20,822.43 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.65 / $1,696.74 / $3,858.36
| Professional | | $1,453.65 | $1,696.74 | $3,858.36 |