- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.28 / $556.28 / $556.28
| Professional | | $556.28 | $556.28 | $556.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.00 / $2,639.00 / $3,167.00
| Professional | | $1,633.00 | $2,639.00 | $3,167.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.88 / $773.39 / $1,117.13
| Professional | | $572.88 | $773.39 | $1,117.13 |
- 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
- $555.17 / $1,104.69 / $1,849.89
| Professional | | $555.17 | $1,104.69 | $1,849.89 |