- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.81 / $883.81 / $883.81
| Professional | | $883.81 | $883.81 | $883.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.00 / $2,285.00 / $2,742.00
| Professional | | $2,026.00 | $2,285.00 | $2,742.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.40 / $1,333.64 / $2,133.44
| Professional | | $1,270.40 | $1,333.64 | $2,133.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.94 / $2,893.17 / $3,728.99
| Professional | | $1,162.94 | $2,893.17 | $3,728.99 |