- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.39 / $427.39 / $623.95
| Professional | | $427.39 | $427.39 | $623.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.00 / $2,030.00 / $2,894.00
| Professional | | $1,255.00 | $2,030.00 | $2,894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.54 / $780.71 / $1,141.04
| Professional | | $571.54 | $780.71 | $1,141.04 |
- 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
- $578.86 / $1,275.72 / $1,857.90
| Professional | | $578.86 | $1,275.72 | $1,857.90 |