- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.30 / $764.30 / $764.30
| Professional | | $764.30 | $764.30 | $764.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.00 / $1,794.00 / $2,243.00
| Professional | | $1,495.00 | $1,794.00 | $2,243.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.74 / $1,282.19 / $1,832.85
| Professional | | $1,032.74 | $1,282.19 | $1,832.85 |
- 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
- $1,179.74 / $1,899.04 / $2,960.75
| Professional | | $1,179.74 | $1,899.04 | $2,960.75 |