- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.03 / $941.03 / $941.03
| Professional | | $941.03 | $941.03 | $941.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.00 / $2,167.00 / $2,600.00
| Professional | | $1,626.00 | $2,167.00 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.28 / $1,221.58 / $1,832.36
| Professional | | $774.28 | $1,221.58 | $1,832.36 |
- 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
- $905.05 / $1,578.61 / $2,848.56
| Professional | | $905.05 | $1,578.61 | $2,848.56 |