- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,237.34
| Professional | | $1,448.30 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $745.00 / $1,095.00
| Professional | | $350.00 | $745.00 | $1,095.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.52 / $198.37 / $198.37
| Professional | | $66.52 | $198.37 | $198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,520.72 / $3,244.19
| Facility | | $1,448.30 | $1,520.72 | $3,244.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,204.94 / $3,204.94 / $3,204.94
| Professional | | $3,204.94 | $3,204.94 | $3,204.94 |