- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.51 / $442.51 / $607.75
| Professional | | $442.51 | $442.51 | $607.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.00 / $1,735.00 / $2,382.00
| Professional | | $1,121.00 | $1,735.00 | $2,382.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.47 / $712.84 / $1,036.20
| Professional | | $490.47 | $712.84 | $1,036.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $2,962.56 / $5,606.00
| Facility | | $1,275.00 | $2,962.56 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.16 / $991.80 / $1,789.68
| Professional | | $622.16 | $991.80 | $1,789.68 |