- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.15 / $462.15 / $462.15
| Professional | | $462.15 | $462.15 | $462.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.00 / $1,179.00 / $1,415.00
| Professional | | $1,046.00 | $1,179.00 | $1,415.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.17 / $725.53 / $1,116.04
| Professional | | $702.17 | $725.53 | $1,116.04 |
- 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
- $693.49 / $1,215.10 / $1,932.48
| Professional | | $693.49 | $1,215.10 | $1,932.48 |