- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.77 / $900.77 / $900.77
| Professional | | $900.77 | $900.77 | $900.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.00 / $2,074.00 / $2,489.00
| Professional | | $1,555.00 | $2,074.00 | $2,489.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.19 / $1,179.59 / $1,769.40
| Professional | | $782.19 | $1,179.59 | $1,769.40 |
- 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
- $893.68 / $1,513.80 / $2,731.62
| Professional | | $893.68 | $1,513.80 | $2,731.62 |