- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.59 / $403.47 / $561.45
| Professional | | $362.59 | $403.47 | $561.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.00 / $1,289.00 / $1,994.00
| Professional | | $1,074.00 | $1,289.00 | $1,994.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.86 / $675.83 / $906.28
| Professional | | $419.86 | $675.83 | $906.28 |
- 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
- $423.86 / $753.59 / $1,568.17
| Professional | | $423.86 | $753.59 | $1,568.17 |