- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.38 / $343.38 / $1,595.44
| Professional | | $343.38 | $343.38 | $1,595.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.00 / $931.00 / $3,818.00
| Professional | | $776.00 | $931.00 | $3,818.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.84 / $832.49 / $3,502.88
| Professional | | $509.84 | $832.49 | $3,502.88 |
- 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
- $2,381.28 / $4,172.39 / $6,635.64
| Professional | | $2,381.28 | $4,172.39 | $6,635.64 |