- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.48 / $664.48 / $664.48
| Professional | | $664.48 | $664.48 | $664.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.00 / $1,097.00 / $2,192.00
| Professional | | $914.00 | $1,097.00 | $2,192.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.69 / $1,467.67 / $2,628.72
| Professional | | $950.69 | $1,467.67 | $2,628.72 |
- 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
- $1,665.95 / $2,814.53 / $4,503.83
| Professional | | $1,665.95 | $2,814.53 | $4,503.83 |