- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.44 / $656.44 / $656.44
| Professional | | $656.44 | $656.44 | $656.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.00 / $1,510.00 / $1,812.00
| Professional | | $1,132.00 | $1,510.00 | $1,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.46 / $803.30 / $1,204.95
| Professional | | $521.46 | $803.30 | $1,204.95 |
- 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
- $635.71 / $1,056.59 / $1,642.29
| Professional | | $635.71 | $1,056.59 | $1,642.29 |