- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.66 / $923.66 / $923.66
| Professional | | $923.66 | $923.66 | $923.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.00 / $2,127.00 / $2,552.00
| Professional | | $1,596.00 | $2,127.00 | $2,552.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.88 / $1,188.02 / $1,782.03
| Professional | | $737.88 | $1,188.02 | $1,782.03 |
- 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
- $906.67 / $1,439.19 / $2,325.39
| Professional | | $906.67 | $1,439.19 | $2,325.39 |