- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.54 / $397.54 / $397.54
| Professional | | $397.54 | $397.54 | $397.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.00 / $937.00 / $1,171.00
| Professional | | $781.00 | $937.00 | $1,171.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.05 / $670.67 / $955.91
| Professional | | $534.05 | $670.67 | $955.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.66 / $886.10 / $1,653.96
| Professional | | $650.66 | $886.10 | $1,653.96 |