- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.37 / $689.37 / $863.03
| Professional | | $689.37 | $689.37 | $863.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.00 / $1,591.00 / $1,990.00
| Professional | | $1,194.00 | $1,591.00 | $1,990.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.46 / $1,034.84 / $1,494.78
| Professional | | $770.46 | $1,034.84 | $1,494.78 |
- 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
- $843.20 / $1,435.79 / $2,590.86
| Professional | | $843.20 | $1,435.79 | $2,590.86 |