- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.26 / $589.26 / $589.26
| Professional | | $589.26 | $589.26 | $589.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.00 / $1,279.00 / $1,867.00
| Professional | | $1,066.00 | $1,279.00 | $1,867.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.06 / $989.00 / $1,384.57
| Professional | | $798.06 | $989.00 | $1,384.57 |
- 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
- $913.00 / $1,826.00 / $2,292.83
| Professional | | $913.00 | $1,826.00 | $2,292.83 |