- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.52 / $876.52 / $876.52
| Professional | | $876.52 | $876.52 | $876.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.00 / $1,939.00 / $2,909.00
| Professional | | $1,616.00 | $1,939.00 | $2,909.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.08 / $1,450.26 / $2,014.62
| Professional | | $1,125.08 | $1,450.26 | $2,014.62 |
- 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
- $1,257.29 / $2,085.80 / $3,346.19
| Professional | | $1,257.29 | $2,085.80 | $3,346.19 |