- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.89 / $623.89 / $623.89
| Professional | | $623.89 | $623.89 | $623.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.00 / $2,955.00 / $3,546.00
| Professional | | $1,828.00 | $2,955.00 | $3,546.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.57 / $866.12 / $1,251.06
| Professional | | $641.57 | $866.12 | $1,251.06 |
- 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
- $565.60 / $1,237.03 / $2,013.69
| Professional | | $565.60 | $1,237.03 | $2,013.69 |