- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.59 / $874.59 / $874.59
| Professional | | $874.59 | $874.59 | $874.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.00 / $1,895.00 / $2,766.00
| Professional | | $1,579.00 | $1,895.00 | $2,766.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.06 / $1,463.93 / $2,048.86
| Professional | | $1,185.06 | $1,463.93 | $2,048.86 |
- 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
- $1,057.30 / $2,211.11 / $3,417.47
| Professional | | $1,057.30 | $2,211.11 | $3,417.47 |