- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.57 / $597.57 / $597.57
| Professional | | $597.57 | $597.57 | $597.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.00 / $1,404.00 / $1,754.00
| Professional | | $1,170.00 | $1,404.00 | $1,754.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.18 / $1,004.04 / $1,393.58
| Professional | | $803.18 | $1,004.04 | $1,393.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $6,897.94 / $10,877.00
| Facility | | $2,607.00 | $6,897.94 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.39 / $1,485.70 / $2,311.33
| Professional | | $713.39 | $1,485.70 | $2,311.33 |