- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.53 / $664.53 / $664.53
| Professional | | $664.53 | $664.53 | $664.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.00 / $1,717.00 / $2,060.00
| Professional | | $1,523.00 | $1,717.00 | $2,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.24 / $893.79 / $1,502.71
| Professional | | $816.24 | $893.79 | $1,502.71 |
- 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
- $696.34 / $1,468.84 / $2,488.19
| Professional | | $696.34 | $1,468.84 | $2,488.19 |