- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.66 / $520.66 / $658.89
| Professional | | $520.66 | $520.66 | $658.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.00 / $1,195.00 / $1,511.00
| Professional | | $896.00 | $1,195.00 | $1,511.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.22 / $776.79 / $1,117.51
| Professional | | $574.22 | $776.79 | $1,117.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.21 / $1,073.40 / $1,936.92
| Professional | | $682.21 | $1,073.40 | $1,936.92 |