- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.80 / $677.80 / $677.80
| Professional | | $677.80 | $677.80 | $677.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.00 / $3,206.00 / $3,847.00
| Professional | | $1,983.00 | $3,206.00 | $3,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.36 / $944.13 / $1,363.75
| Professional | | $699.36 | $944.13 | $1,363.75 |
- 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
- $684.93 / $1,349.88 / $2,303.60
| Professional | | $684.93 | $1,349.88 | $2,303.60 |