- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.44 / $717.44 / $717.44
| Professional | | $717.44 | $717.44 | $717.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.00 / $1,558.00 / $2,273.00
| Professional | | $1,298.00 | $1,558.00 | $2,273.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.01 / $1,203.38 / $1,673.09
| Professional | | $967.01 | $1,203.38 | $1,673.09 |
- 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
- $1,137.40 / $1,850.06 / $2,881.56
| Professional | | $1,137.40 | $1,850.06 | $2,881.56 |