- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.87 / $617.87 / $617.87
| Professional | | $617.87 | $617.87 | $617.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.00 / $1,258.00 / $2,515.00
| Professional | | $1,048.00 | $1,258.00 | $2,515.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.77 / $1,090.11 / $1,455.07
| Professional | | $843.77 | $1,090.11 | $1,455.07 |
- 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
- $988.89 / $1,492.35 / $2,373.38
| Professional | | $988.89 | $1,492.35 | $2,373.38 |