- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.58 / $409.67 / $553.74
| Professional | | $376.58 | $409.67 | $553.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.00 / $1,255.00 / $1,943.00
| Professional | | $1,046.00 | $1,255.00 | $1,943.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.75 / $677.34 / $977.68
| Professional | | $403.75 | $677.34 | $977.68 |
- 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
- $468.45 / $708.01 / $1,559.98
| Professional | | $468.45 | $708.01 | $1,559.98 |