- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.63 / $617.90 / $934.59
| Professional | | $491.63 | $617.90 | $934.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.00 / $2,222.00 / $3,438.00
| Professional | | $1,852.00 | $2,222.00 | $3,438.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.70 / $1,189.68 / $2,429.16
| Professional | | $742.70 | $1,189.68 | $2,429.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.78 / $1,236.18 / $2,614.23
| Professional | | $654.78 | $1,236.18 | $2,614.23 |