- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.47 / $756.47 / $756.47
| Professional | | $756.47 | $756.47 | $756.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.00 / $1,638.00 / $2,392.00
| Professional | | $1,365.00 | $1,638.00 | $2,392.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,265.56 / $1,873.51
| Professional | | $1,028.40 | $1,265.56 | $1,873.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.84 / $1,921.44 / $2,968.70
| Professional | | $1,202.84 | $1,921.44 | $2,968.70 |