- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.48 / $605.48 / $605.48
| Professional | | $605.48 | $605.48 | $605.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.00 / $1,544.00 / $1,853.00
| Professional | | $1,369.00 | $1,544.00 | $1,853.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.96 / $917.81 / $1,480.66
| Professional | | $872.96 | $917.81 | $1,480.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.98 / $2,029.51 / $2,435.39
| Professional | | $873.98 | $2,029.51 | $2,435.39 |