- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.19 / $687.19 / $687.19
| Professional | | $687.19 | $687.19 | $687.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.00 / $1,772.00 / $2,126.00
| Professional | | $1,571.00 | $1,772.00 | $2,126.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.35 / $1,049.97 / $1,726.43
| Professional | | $1,031.35 | $1,049.97 | $1,726.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.03 / $2,348.51 / $3,004.34
| Professional | | $900.03 | $2,348.51 | $3,004.34 |