- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.87 / $665.87 / $665.87
| Professional | | $665.87 | $665.87 | $665.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.00 / $1,454.00 / $2,123.00
| Professional | | $1,212.00 | $1,454.00 | $2,123.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.26 / $1,126.68 / $1,530.81
| Professional | | $884.26 | $1,126.68 | $1,530.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,732.00 / $12,732.00 / $31,027.00
| Facility | | $12,732.00 | $12,732.00 | $31,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.15 / $1,322.01 / $2,572.67
| Professional | | $1,030.15 | $1,322.01 | $2,572.67 |