- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.61 / $612.45 / $860.98
| Professional | | $565.61 | $612.45 | $860.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.00 / $1,913.00 / $2,959.00
| Professional | | $1,594.00 | $1,913.00 | $2,959.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.66 / $1,033.53 / $1,509.45
| Professional | | $601.66 | $1,033.53 | $1,509.45 |
- 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
- $696.71 / $1,222.40 / $2,178.80
| Professional | | $696.71 | $1,222.40 | $2,178.80 |