- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.89 / $501.89 / $501.89
| Professional | | $501.89 | $501.89 | $501.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,031.00 / $1,237.00
| Professional | | $1,031.00 | $1,031.00 | $1,237.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.54 / $833.11 / $1,072.96
| Professional | | $592.54 | $833.11 | $1,072.96 |
- 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
- $668.79 / $1,118.83 / $1,787.28
| Professional | | $668.79 | $1,118.83 | $1,787.28 |