- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.11 / $474.11 / $652.66
| Professional | | $474.11 | $474.11 | $652.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.00 / $2,252.00 / $3,044.00
| Professional | | $1,393.00 | $2,252.00 | $3,044.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.44 / $841.60 / $1,230.04
| Professional | | $632.44 | $841.60 | $1,230.04 |
- 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
- $680.23 / $1,209.29 / $2,051.38
| Professional | | $680.23 | $1,209.29 | $2,051.38 |