- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.52 / $801.52 / $801.52
| Professional | | $801.52 | $801.52 | $801.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.00 / $1,738.00 / $2,537.00
| Professional | | $1,448.00 | $1,738.00 | $2,537.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.70 / $1,343.25 / $1,960.32
| Professional | | $1,070.70 | $1,343.25 | $1,960.32 |
- 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
- $1,202.30 / $1,926.42 / $3,029.39
| Professional | | $1,202.30 | $1,926.42 | $3,029.39 |