- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.82 / $339.49 / $834.96
| Professional | | $316.82 | $339.49 | $834.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.00 / $1,105.00 / $2,628.00
| Professional | | $757.00 | $1,105.00 | $2,628.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.88 / $781.13 / $1,998.83
| Professional | | $411.88 | $781.13 | $1,998.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.81 / $2,053.87 / $3,462.37
| Professional | | $1,152.81 | $2,053.87 | $3,462.37 |