- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.07 / $5,799.75 / $5,799.75
| Professional | | $324.07 | $5,799.75 | $5,799.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.00 / $368.00 / $801.00
| Professional | | $295.00 | $368.00 | $801.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.74 / $357.36 / $629.48
| Professional | | $206.74 | $357.36 | $629.48 |
- 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
- $462.55 / $638.02 / $1,102.18
| Professional | | $462.55 | $638.02 | $1,102.18 |