- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.48 / $635.48 / $635.48
| Professional | | $635.48 | $635.48 | $635.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.00 / $1,493.00 / $1,866.00
| Professional | | $1,244.00 | $1,493.00 | $1,866.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.12 / $1,067.81 / $1,483.61
| Professional | | $855.12 | $1,067.81 | $1,483.61 |
- 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
- $1,002.09 / $1,603.55 / $2,477.66
| Professional | | $1,002.09 | $1,603.55 | $2,477.66 |