- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.23 / $848.23 / $848.23
| Professional | | $848.23 | $848.23 | $848.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.00 / $1,824.00 / $2,662.00
| Professional | | $1,520.00 | $1,824.00 | $2,662.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.30 / $1,411.56 / $1,923.70
| Professional | | $1,069.30 | $1,411.56 | $1,923.70 |
- 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
- $1,213.31 / $1,822.64 / $3,294.73
| Professional | | $1,213.31 | $1,822.64 | $3,294.73 |