- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.46 / $688.46 / $688.46
| Professional | | $688.46 | $688.46 | $688.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.00 / $1,495.00 / $2,183.00
| Professional | | $1,246.00 | $1,495.00 | $2,183.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.52 / $1,155.60 / $1,682.18
| Professional | | $909.52 | $1,155.60 | $1,682.18 |
- 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
- $1,054.33 / $1,700.68 / $2,815.55
| Professional | | $1,054.33 | $1,700.68 | $2,815.55 |