- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.80 / $385.80 / $1,329.51
| Professional | | $385.80 | $385.80 | $1,329.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.00 / $1,060.00 / $3,161.00
| Professional | | $883.00 | $1,060.00 | $3,161.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.80 / $800.07 / $2,308.46
| Professional | | $470.80 | $800.07 | $2,308.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.42 / $3,238.40 / $5,215.34
| Professional | | $1,496.42 | $3,238.40 | $5,215.34 |