- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.66 / $635.84 / $945.48
| Professional | | $616.66 | $635.84 | $945.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.00 / $2,183.00 / $3,377.00
| Professional | | $1,819.00 | $2,183.00 | $3,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.23 / $1,158.35 / $1,533.15
| Professional | | $712.23 | $1,158.35 | $1,533.15 |
- 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
- $720.86 / $1,268.19 / $2,646.58
| Professional | | $720.86 | $1,268.19 | $2,646.58 |