- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.87 / $571.87 / $571.87
| Professional | | $571.87 | $571.87 | $571.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.00 / $1,473.00 / $1,768.00
| Professional | | $1,307.00 | $1,473.00 | $1,768.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.23 / $836.40 / $1,371.01
| Professional | | $806.23 | $836.40 | $1,371.01 |
- 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
- $799.13 / $1,400.20 / $2,226.82
| Professional | | $799.13 | $1,400.20 | $2,226.82 |