- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.05 / $411.05 / $411.05
| Professional | | $411.05 | $411.05 | $411.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.00 / $1,949.00 / $2,339.00
| Professional | | $1,205.00 | $1,949.00 | $2,339.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.08 / $567.10 / $819.15
| Professional | | $420.08 | $567.10 | $819.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $4,665.92 / $10,877.00
| Facility | | $2,607.00 | $4,665.92 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.28 / $812.86 / $1,306.49
| Professional | | $436.28 | $812.86 | $1,306.49 |