- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.78 / $2,278.96 / $3,706.72
| Professional | | $1,892.78 | $2,278.96 | $3,706.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.00 / $726.00 / $791.00
| Professional | | $726.00 | $726.00 | $791.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.40 / $678.60 / $1,229.09
| Professional | | $568.40 | $678.60 | $1,229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.51 / $8,444.70 / $26,542.00
| Facility | | $1,346.51 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,124.46 / $4,124.46 / $4,124.46
| Professional | | $4,124.46 | $4,124.46 | $4,124.46 |