- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.46 / $644.46 / $644.46
| Professional | | $644.46 | $644.46 | $644.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.00 / $2,551.00 / $3,061.00
| Professional | | $1,649.00 | $2,551.00 | $3,061.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.87 / $844.46 / $1,266.69
| Professional | | $600.87 | $844.46 | $1,266.69 |
- 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
- $719.50 / $1,063.80 / $1,919.61
| Professional | | $719.50 | $1,063.80 | $1,919.61 |