- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.86 / $503.57 / $707.84
| Professional | | $460.86 | $503.57 | $707.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,560.00 / $2,413.00
| Professional | | $1,300.00 | $1,560.00 | $2,413.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.22 / $843.92 / $1,173.74
| Professional | | $487.22 | $843.92 | $1,173.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.20 / $937.88 / $1,769.30
| Professional | | $499.20 | $937.88 | $1,769.30 |