- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.21 / $683.21 / $683.21
| Professional | | $683.21 | $683.21 | $683.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.00 / $2,174.00 / $2,609.00
| Professional | | $1,087.00 | $2,174.00 | $2,609.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.03 / $1,133.58 / $1,607.00
| Professional | | $875.03 | $1,133.58 | $1,607.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.35 / $1,701.51 / $2,739.00
| Professional | | $999.35 | $1,701.51 | $2,739.00 |