- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.66 / $626.66 / $626.66
| Professional | | $626.66 | $626.66 | $626.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.00 / $1,385.00 / $2,077.00
| Professional | | $1,154.00 | $1,385.00 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.41 / $1,039.35 / $1,305.03
| Professional | | $717.41 | $1,039.35 | $1,305.03 |
- 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
- $806.30 / $1,347.93 / $2,170.09
| Professional | | $806.30 | $1,347.93 | $2,170.09 |