- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.67 / $684.67 / $873.77
| Professional | | $684.67 | $684.67 | $873.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.00 / $1,566.00 / $2,004.00
| Professional | | $1,175.00 | $1,566.00 | $2,004.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.81 / $1,038.88 / $1,525.65
| Professional | | $751.81 | $1,038.88 | $1,525.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.68 / $1,512.00 / $2,728.38
| Professional | | $888.68 | $1,512.00 | $2,728.38 |