- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.41 / $384.41 / $503.69
| Professional | | $384.41 | $384.41 | $503.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.00 / $875.00 / $1,151.00
| Professional | | $657.00 | $875.00 | $1,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.64 / $758.34 / $1,146.42
| Professional | | $516.64 | $758.34 | $1,146.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.61 / $921.01 / $1,601.60
| Professional | | $612.61 | $921.01 | $1,601.60 |