- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.73 / $719.73 / $719.73
| Professional | | $719.73 | $719.73 | $719.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.00 / $1,525.00 / $2,226.00
| Professional | | $1,271.00 | $1,525.00 | $2,226.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.91 / $1,185.21 / $1,481.07
| Professional | | $801.91 | $1,185.21 | $1,481.07 |
- 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
- $916.85 / $1,570.35 / $2,542.30
| Professional | | $916.85 | $1,570.35 | $2,542.30 |