- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.86 / $456.86 / $633.35
| Professional | | $456.86 | $456.86 | $633.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.00 / $2,174.00 / $2,957.00
| Professional | | $1,345.00 | $2,174.00 | $2,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.96 / $796.42 / $1,163.99
| Professional | | $610.96 | $796.42 | $1,163.99 |
- 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
- $645.16 / $1,216.13 / $1,959.08
| Professional | | $645.16 | $1,216.13 | $1,959.08 |