- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.30 / $428.30 / $460.49
| Professional | | $428.30 | $428.30 | $460.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.00 / $837.00 / $1,221.00
| Professional | | $778.00 | $837.00 | $1,221.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.69 / $723.02 / $1,060.16
| Professional | | $572.69 | $723.02 | $1,060.16 |
- 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
- $707.31 / $1,416.15 / $1,767.47
| Professional | | $707.31 | $1,416.15 | $1,767.47 |