- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.63 / $460.63 / $595.24
| Professional | | $460.63 | $460.63 | $595.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.00 / $2,171.00 / $2,795.00
| Professional | | $1,343.00 | $2,171.00 | $2,795.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.48 / $763.72 / $1,116.20
| Professional | | $587.48 | $763.72 | $1,116.20 |
- 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
- $567.49 / $1,284.93 / $1,808.29
| Professional | | $567.49 | $1,284.93 | $1,808.29 |