- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.31 / $672.31 / $672.31
| Professional | | $672.31 | $672.31 | $672.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.00 / $1,494.00 / $2,240.00
| Professional | | $1,245.00 | $1,494.00 | $2,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.56 / $1,123.99 / $1,470.65
| Professional | | $844.56 | $1,123.99 | $1,470.65 |
- 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
- $948.20 / $2,057.10 / $2,521.21
| Professional | | $948.20 | $2,057.10 | $2,521.21 |