- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.58 / $812.58 / $812.58
| Professional | | $812.58 | $812.58 | $812.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.00 / $1,894.00 / $2,366.00
| Professional | | $1,578.00 | $1,894.00 | $2,366.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.82 / $1,354.31 / $1,830.31
| Professional | | $1,047.82 | $1,354.31 | $1,830.31 |
- 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
- $1,205.06 / $1,769.88 / $3,084.84
| Professional | | $1,205.06 | $1,769.88 | $3,084.84 |