- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.39 / $679.39 / $679.39
| Professional | | $679.39 | $679.39 | $679.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.00 / $1,480.00 / $2,160.00
| Professional | | $1,233.00 | $1,480.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.66 / $1,144.78 / $1,586.49
| Professional | | $924.66 | $1,144.78 | $1,586.49 |
- 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
- $1,076.90 / $2,107.98 / $2,545.39
| Professional | | $1,076.90 | $2,107.98 | $2,545.39 |