- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.43 / $712.43 / $712.43
| Professional | | $712.43 | $712.43 | $712.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.00 / $1,357.00 / $2,716.00
| Professional | | $1,131.00 | $1,357.00 | $2,716.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.10 / $1,181.72 / $1,592.83
| Professional | | $861.10 | $1,181.72 | $1,592.83 |
- 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
- $986.15 / $1,693.20 / $2,745.59
| Professional | | $986.15 | $1,693.20 | $2,745.59 |