- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.29 / $859.29 / $859.29
| Professional | | $859.29 | $859.29 | $859.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.00 / $1,633.00 / $3,268.00
| Professional | | $1,361.00 | $1,633.00 | $3,268.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.63 / $1,421.59 / $1,922.61
| Professional | | $1,049.63 | $1,421.59 | $1,922.61 |
- 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
- $944.55 / $1,828.08 / $3,315.82
| Professional | | $944.55 | $1,828.08 | $3,315.82 |