- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.71 / $428.26 / $646.53
| Professional | | $413.71 | $428.26 | $646.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.00 / $1,468.00 / $2,272.00
| Professional | | $1,223.00 | $1,468.00 | $2,272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.19 / $782.63 / $1,075.14
| Professional | | $475.19 | $782.63 | $1,075.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.29 / $959.24 / $1,520.99
| Professional | | $482.29 | $959.24 | $1,520.99 |