- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.56 / $367.56 / $387.28
| Professional | | $367.56 | $367.56 | $387.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.00 / $1,747.00 / $1,837.00
| Professional | | $1,081.00 | $1,747.00 | $1,837.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.25 / $512.53 / $749.08
| Professional | | $394.25 | $512.53 | $749.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.70 / $763.39 / $1,266.19
| Professional | | $392.70 | $763.39 | $1,266.19 |