- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.67 / $278.67 / $393.56
| Professional | | $278.67 | $278.67 | $393.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.00 / $698.00 / $1,019.00
| Professional | | $506.00 | $698.00 | $1,019.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.47 / $579.60 / $1,001.70
| Professional | | $376.47 | $579.60 | $1,001.70 |
- 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
- $707.41 / $1,176.11 / $1,770.10
| Professional | | $707.41 | $1,176.11 | $1,770.10 |