- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.21 / $604.21 / $604.21
| Professional | | $604.21 | $604.21 | $604.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.00 / $1,488.00 / $2,550.00
| Professional | | $1,240.00 | $1,488.00 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.46 / $1,013.17 / $1,375.73
| Professional | | $757.46 | $1,013.17 | $1,375.73 |
- 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
- $855.80 / $1,445.86 / $2,321.87
| Professional | | $855.80 | $1,445.86 | $2,321.87 |