- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.91 / $633.33 / $933.12
| Professional | | $627.91 | $633.33 | $933.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.00 / $2,166.00 / $3,350.00
| Professional | | $1,805.00 | $2,166.00 | $3,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.01 / $1,151.89 / $1,616.69
| Professional | | $730.01 | $1,151.89 | $1,616.69 |
- 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
- $770.72 / $1,388.19 / $2,403.69
| Professional | | $770.72 | $1,388.19 | $2,403.69 |