- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.93 / $2,066.03 / $3,360.38
| Professional | | $1,715.93 | $2,066.03 | $3,360.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.00 / $654.00 / $711.00
| Professional | | $654.00 | $654.00 | $711.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.50 / $557.70 / $1,110.09
| Professional | | $466.50 | $557.70 | $1,110.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.07 / $8,444.70 / $26,542.00
| Facility | | $1,216.07 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,609.32 / $3,609.32 / $3,609.32
| Professional | | $3,609.32 | $3,609.32 | $3,609.32 |