- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.11 / $521.11 / $521.11
| Professional | | $521.11 | $521.11 | $521.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.00 / $1,323.00 / $1,588.00
| Professional | | $1,173.00 | $1,323.00 | $1,588.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.20 / $751.49 / $1,230.50
| Professional | | $737.20 | $751.49 | $1,230.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,732.00 / $12,732.00 / $31,027.00
| Facility | | $12,732.00 | $12,732.00 | $31,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.13 / $1,357.04 / $2,080.31
| Professional | | $637.13 | $1,357.04 | $2,080.31 |