- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.58 / $370.58 / $521.08
| Professional | | $370.58 | $370.58 | $521.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.00 / $1,451.00 / $2,039.00
| Professional | | $938.00 | $1,451.00 | $2,039.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.85 / $613.69 / $894.05
| Professional | | $447.85 | $613.69 | $894.05 |
- 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
- $543.03 / $853.19 / $1,539.57
| Professional | | $543.03 | $853.19 | $1,539.57 |