- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.51 / $496.51 / $496.51
| Professional | | $496.51 | $496.51 | $496.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.00 / $1,266.00 / $1,519.00
| Professional | | $1,123.00 | $1,266.00 | $1,519.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.60 / $747.58 / $1,220.17
| Professional | | $720.60 | $747.58 | $1,220.17 |
- 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
- $638.54 / $1,342.94 / $2,080.31
| Professional | | $638.54 | $1,342.94 | $2,080.31 |