- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.29 / $472.29 / $472.29
| Professional | | $472.29 | $472.29 | $472.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.00 / $1,221.00 / $1,465.00
| Professional | | $1,083.00 | $1,221.00 | $1,465.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.49 / $710.15 / $1,177.73
| Professional | | $697.49 | $710.15 | $1,177.73 |
- 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
- $599.88 / $1,318.86 / $2,052.58
| Professional | | $599.88 | $1,318.86 | $2,052.58 |