- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.47 / $670.47 / $670.47
| Professional | | $670.47 | $670.47 | $670.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.00 / $1,539.00 / $1,847.00
| Professional | | $1,154.00 | $1,539.00 | $1,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.98 / $772.28 / $1,158.42
| Professional | | $533.98 | $772.28 | $1,158.42 |
- 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
- $611.71 / $1,111.80 / $1,969.48
| Professional | | $611.71 | $1,111.80 | $1,969.48 |