- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.13 / $561.90 / $844.44
| Professional | | $535.13 | $561.90 | $844.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.00 / $1,921.00 / $2,972.00
| Professional | | $1,601.00 | $1,921.00 | $2,972.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.66 / $1,023.77 / $1,337.05
| Professional | | $620.66 | $1,023.77 | $1,337.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.20 / $1,105.65 / $2,290.19
| Professional | | $613.20 | $1,105.65 | $2,290.19 |