- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.70 / $654.70 / $7,108.06
| Professional | | $654.70 | $654.70 | $7,108.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.00 / $1,770.00 / $16,657.00
| Professional | | $1,475.00 | $1,770.00 | $16,657.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.42 / $1,581.72 / $15,410.09
| Professional | | $953.42 | $1,581.72 | $15,410.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,592.44 / $22,461.70 / $25,421.87
| Professional | | $10,592.44 | $22,461.70 | $25,421.87 |