- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.37 / $388.83 / $584.92
| Professional | | $363.37 | $388.83 | $584.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.00 / $1,338.00 / $2,070.00
| Professional | | $1,115.00 | $1,338.00 | $2,070.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.03 / $656.03 / $927.33
| Professional | | $433.03 | $656.03 | $927.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.74 / $765.45 / $1,517.99
| Professional | | $427.74 | $765.45 | $1,517.99 |