- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.69 / $622.69 / $768.38
| Professional | | $622.69 | $622.69 | $768.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.00 / $1,716.00 / $1,900.00
| Professional | | $1,430.00 | $1,716.00 | $1,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.56 / $1,040.90 / $1,617.45
| Professional | | $729.56 | $1,040.90 | $1,617.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.70 / $2,017.40 / $2,728.45
| Professional | | $1,008.70 | $2,017.40 | $2,728.45 |