- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.82 / $500.82 / $500.82
| Professional | | $500.82 | $500.82 | $500.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.00 / $2,859.00 / $3,431.00
| Professional | | $1,768.00 | $2,859.00 | $3,431.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.80 / $797.59 / $1,152.07
| Professional | | $590.80 | $797.59 | $1,152.07 |
- 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
- $572.13 / $1,166.69 / $1,874.61
| Professional | | $572.13 | $1,166.69 | $1,874.61 |