- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.72 / $714.72 / $714.72
| Professional | | $714.72 | $714.72 | $714.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.00 / $1,678.00 / $2,096.00
| Professional | | $1,398.00 | $1,678.00 | $2,096.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.22 / $1,198.95 / $1,668.89
| Professional | | $964.22 | $1,198.95 | $1,668.89 |
- 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
- $1,119.24 / $1,794.46 / $2,782.55
| Professional | | $1,119.24 | $1,794.46 | $2,782.55 |