- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.38 / $917.38 / $917.38
| Professional | | $917.38 | $917.38 | $917.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.00 / $2,111.00 / $2,533.00
| Professional | | $1,583.00 | $2,111.00 | $2,533.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.76 / $1,201.39 / $1,802.08
| Professional | | $781.76 | $1,201.39 | $1,802.08 |
- 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
- $913.24 / $1,543.81 / $2,785.77
| Professional | | $913.24 | $1,543.81 | $2,785.77 |