- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.48 / $560.48 / $560.48
| Professional | | $560.48 | $560.48 | $560.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.00 / $1,242.00 / $1,864.00
| Professional | | $1,035.00 | $1,242.00 | $1,864.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.17 / $930.75 / $1,216.08
| Professional | | $710.17 | $930.75 | $1,216.08 |
- 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
- $632.86 / $1,462.45 / $2,415.61
| Professional | | $632.86 | $1,462.45 | $2,415.61 |