- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.07 / $951.07 / $951.07
| Professional | | $951.07 | $951.07 | $951.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.00 / $2,179.00 / $2,615.00
| Professional | | $1,634.00 | $2,179.00 | $2,615.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.27 / $1,238.59 / $1,857.90
| Professional | | $820.27 | $1,238.59 | $1,857.90 |
- 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
- $1,035.76 / $1,594.20 / $2,876.70
| Professional | | $1,035.76 | $1,594.20 | $2,876.70 |