- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.62 / $372.62 / $511.40
| Professional | | $372.62 | $372.62 | $511.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.00 / $909.00 / $1,326.00
| Professional | | $675.00 | $909.00 | $1,326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.33 / $628.23 / $1,018.78
| Professional | | $437.33 | $628.23 | $1,018.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $6,486.14 / $10,877.00
| Facility | | $2,607.00 | $6,486.14 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.49 / $1,073.18 / $1,743.73
| Professional | | $621.49 | $1,073.18 | $1,743.73 |