- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.71 / $422.71 / $479.12
| Professional | | $422.71 | $422.71 | $479.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.00 / $2,006.00 / $2,263.00
| Professional | | $1,241.00 | $2,006.00 | $2,263.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.45 / $627.17 / $916.65
| Professional | | $482.45 | $627.17 | $916.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.59 / $1,048.28 / $1,514.50
| Professional | | $484.59 | $1,048.28 | $1,514.50 |