- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.80 / $261.80 / $4,923.67
| Professional | | $261.80 | $261.80 | $4,923.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.00 / $1,837.00 / $1,837.00
| Professional | | $1,837.00 | $1,837.00 | $1,837.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.79 / $360.79 / $360.79
| Facility | | $360.79 | $360.79 | $360.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.00 / $33.00 / $33.00
| Professional | | $33.00 | $33.00 | $33.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.00 / $2,904.00 / $3,501.00
| Professional | | $2,247.00 | $2,904.00 | $3,501.00 |