- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.09 / $955.09 / $955.09
| Professional | | $955.09 | $955.09 | $955.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.00 / $2,200.00 / $2,640.00
| Professional | | $1,650.00 | $2,200.00 | $2,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.19 / $1,268.25 / $1,902.37
| Professional | | $828.19 | $1,268.25 | $1,902.37 |
- 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
- $935.07 / $1,618.81 / $2,921.10
| Professional | | $935.07 | $1,618.81 | $2,921.10 |