- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.81 / $334.81 / $1,577.52
| Professional | | $334.81 | $334.81 | $1,577.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.00 / $919.00 / $3,717.00
| Professional | | $766.00 | $919.00 | $3,717.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.12 / $743.54 / $2,836.57
| Professional | | $415.12 | $743.54 | $2,836.57 |
- 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
- $1,664.85 / $3,283.72 / $4,734.66
| Professional | | $1,664.85 | $3,283.72 | $4,734.66 |