- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.66 / $687.66 / $687.66
| Professional | | $687.66 | $687.66 | $687.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.00 / $1,406.00 / $1,687.00
| Professional | | $1,406.00 | $1,406.00 | $1,687.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.78 / $1,130.98 / $1,578.01
| Professional | | $897.78 | $1,130.98 | $1,578.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.15 / $1,646.71 / $2,748.23
| Professional | | $1,008.15 | $1,646.71 | $2,748.23 |