- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.44 / $840.44 / $840.44
| Professional | | $840.44 | $840.44 | $840.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.00 / $1,792.00 / $2,614.00
| Professional | | $1,493.00 | $1,792.00 | $2,614.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.68 / $1,388.93 / $1,775.16
| Professional | | $991.68 | $1,388.93 | $1,775.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.18 / $1,910.67 / $3,061.07
| Professional | | $906.18 | $1,910.67 | $3,061.07 |