- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.18 / $754.18 / $754.18
| Professional | | $754.18 | $754.18 | $754.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.00 / $1,855.00 / $2,987.00
| Professional | | $1,546.00 | $1,855.00 | $2,987.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.95 / $1,258.95 / $1,779.16
| Professional | | $929.95 | $1,258.95 | $1,779.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.39 / $2,098.78 / $2,904.01
| Professional | | $1,049.39 | $2,098.78 | $2,904.01 |