- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.20 / $478.20 / $530.80
| Professional | | $478.20 | $478.20 | $530.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.00 / $2,274.00 / $2,511.00
| Professional | | $1,407.00 | $2,274.00 | $2,511.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.34 / $698.54 / $1,020.95
| Professional | | $537.34 | $698.54 | $1,020.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.17 / $1,164.66 / $1,651.01
| Professional | | $537.17 | $1,164.66 | $1,651.01 |