- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.29 / $609.72 / $853.44
| Professional | | $568.29 | $609.72 | $853.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.00 / $1,950.00 / $3,018.00
| Professional | | $1,625.00 | $1,950.00 | $3,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.59 / $1,053.25 / $1,498.59
| Professional | | $615.59 | $1,053.25 | $1,498.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.57 / $1,101.99 / $2,507.98
| Professional | | $693.57 | $1,101.99 | $2,507.98 |