- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.30 / $563.30 / $563.30
| Professional | | $563.30 | $563.30 | $563.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.00 / $1,220.00 / $1,781.00
| Professional | | $1,017.00 | $1,220.00 | $1,781.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.09 / $929.32 / $1,295.14
| Professional | | $688.09 | $929.32 | $1,295.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.74 / $1,295.61 / $2,077.67
| Professional | | $772.74 | $1,295.61 | $2,077.67 |