- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.46 / $564.46 / $564.46
| Professional | | $564.46 | $564.46 | $564.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.00 / $2,679.00 / $3,215.00
| Professional | | $1,657.00 | $2,679.00 | $3,215.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.72 / $782.63 / $1,130.46
| Professional | | $579.72 | $782.63 | $1,130.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.70 / $1,118.63 / $1,860.29
| Professional | | $572.70 | $1,118.63 | $1,860.29 |