- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.57 / $502.57 / $502.57
| Professional | | $502.57 | $502.57 | $502.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.00 / $2,379.00 / $2,855.00
| Professional | | $1,472.00 | $2,379.00 | $2,855.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.07 / $699.39 / $1,010.23
| Professional | | $518.07 | $699.39 | $1,010.23 |
- 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
- $531.97 / $1,111.89 / $1,624.99
| Professional | | $531.97 | $1,111.89 | $1,624.99 |