- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.89 / $532.30 / $765.41
| Professional | | $412.89 | $532.30 | $765.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.00 / $1,806.00 / $2,794.00
| Professional | | $1,505.00 | $1,806.00 | $2,794.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.34 / $966.64 / $2,495.61
| Professional | | $636.34 | $966.64 | $2,495.61 |
- 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
- $560.94 / $1,036.30 / $3,309.71
| Professional | | $560.94 | $1,036.30 | $3,309.71 |