- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.42 / $560.77 / $837.20
| Professional | | $515.42 | $560.77 | $837.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.00 / $1,925.00 / $2,978.00
| Professional | | $1,604.00 | $1,925.00 | $2,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.78 / $982.64 / $1,350.28
| Professional | | $626.78 | $982.64 | $1,350.28 |
- 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
- $660.37 / $1,098.65 / $2,104.08
| Professional | | $660.37 | $1,098.65 | $2,104.08 |