- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.42 / $507.42 / $507.42
| Professional | | $507.42 | $507.42 | $507.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.00 / $1,295.00 / $1,554.00
| Professional | | $1,148.00 | $1,295.00 | $1,554.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.37 / $793.36 / $1,225.46
| Professional | | $767.37 | $793.36 | $1,225.46 |
- 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
- $880.56 / $1,666.99 / $2,113.31
| Professional | | $880.56 | $1,666.99 | $2,113.31 |