- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.06 / $468.06 / $578.11
| Professional | | $468.06 | $468.06 | $578.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.00 / $2,223.00 / $2,712.00
| Professional | | $1,375.00 | $2,223.00 | $2,712.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.38 / $744.10 / $1,087.52
| Professional | | $572.38 | $744.10 | $1,087.52 |
- 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
- $587.86 / $1,121.41 / $1,838.19
| Professional | | $587.86 | $1,121.41 | $1,838.19 |