- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.26 / $439.26 / $439.26
| Professional | | $439.26 | $439.26 | $439.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.00 / $2,084.00 / $2,501.00
| Professional | | $1,289.00 | $2,084.00 | $2,501.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.93 / $603.35 / $871.51
| Professional | | $446.93 | $603.35 | $871.51 |
- 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
- $454.27 / $865.78 / $1,462.50
| Professional | | $454.27 | $865.78 | $1,462.50 |