- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $749.13 / $749.13 / $749.13
| Professional | | $749.13 | $749.13 | $749.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.00 / $1,624.00 / $2,370.00
| Professional | | $1,353.00 | $1,624.00 | $2,370.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.34 / $1,254.85 / $1,750.77
| Professional | | $1,015.34 | $1,254.85 | $1,750.77 |
- 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
- $1,194.05 / $1,907.34 / $2,940.97
| Professional | | $1,194.05 | $1,907.34 | $2,940.97 |