- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.71 / $380.71 / $380.71
| Professional | | $380.71 | $380.71 | $380.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.00 / $1,176.00 / $1,819.00
| Professional | | $980.00 | $1,176.00 | $1,819.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.32 / $620.70 / $853.36
| Professional | | $500.32 | $620.70 | $853.36 |
- 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
- $578.04 / $872.32 / $1,387.34
| Professional | | $578.04 | $872.32 | $1,387.34 |