- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.33 / $481.77 / $803.77
| Professional | | $372.33 | $481.77 | $803.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.00 / $1,453.00 / $2,249.00
| Professional | | $1,119.00 | $1,453.00 | $2,249.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.47 / $761.68 / $1,242.41
| Professional | | $449.47 | $761.68 | $1,242.41 |
- 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
- $557.57 / $990.99 / $2,031.49
| Professional | | $557.57 | $990.99 | $2,031.49 |