- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.28 / $973.28 / $973.28
| Professional | | $973.28 | $973.28 | $973.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.00 / $2,196.00 / $2,635.00
| Professional | | $1,647.00 | $2,196.00 | $2,635.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.86 / $1,224.06 / $1,836.10
| Professional | | $818.86 | $1,224.06 | $1,836.10 |
- 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
- $972.36 / $1,585.80 / $2,861.55
| Professional | | $972.36 | $1,585.80 | $2,861.55 |