- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.15 / $703.15 / $703.15
| Professional | | $703.15 | $703.15 | $703.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.00 / $1,484.00 / $2,166.00
| Professional | | $1,237.00 | $1,484.00 | $2,166.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.18 / $1,155.69 / $1,433.02
| Professional | | $763.18 | $1,155.69 | $1,433.02 |
- 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
- $876.69 / $1,511.43 / $2,459.16
| Professional | | $876.69 | $1,511.43 | $2,459.16 |