- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.50 / $570.50 / $570.50
| Professional | | $570.50 | $570.50 | $570.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.00 / $1,241.00 / $1,811.00
| Professional | | $1,034.00 | $1,241.00 | $1,811.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.48 / $959.40 / $1,322.92
| Professional | | $765.48 | $959.40 | $1,322.92 |
- 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
- $888.25 / $1,426.76 / $2,211.00
| Professional | | $888.25 | $1,426.76 | $2,211.00 |