- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.88 / $575.88 / $575.88
| Professional | | $575.88 | $575.88 | $575.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.00 / $1,276.00 / $1,914.00
| Professional | | $1,063.00 | $1,276.00 | $1,914.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.92 / $955.91 / $1,235.63
| Professional | | $712.92 | $955.91 | $1,235.63 |
- 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
- $627.17 / $1,330.48 / $2,082.94
| Professional | | $627.17 | $1,330.48 | $2,082.94 |