- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.58 / $1,937.98 / $3,152.11
| Professional | | $1,609.58 | $1,937.98 | $3,152.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.00 / $588.00 / $665.00
| Professional | | $588.00 | $588.00 | $665.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.40 / $572.60 / $1,043.90
| Professional | | $478.40 | $572.60 | $1,043.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,265.67 / $8,444.70 / $26,542.00
| Facility | | $1,265.67 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,713.33 / $3,713.33 / $3,713.33
| Professional | | $3,713.33 | $3,713.33 | $3,713.33 |