- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.86 / $1,555.86 / $1,944.83
| Professional | | $1,555.86 | $1,555.86 | $1,944.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,621.03 / $1,621.03
| Professional | | $150.00 | $1,621.03 | $1,621.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $841.88 / $1,217.70 / $1,803.59
| Facility | | $841.88 | $1,217.70 | $1,803.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.00 / $4,273.00 / $4,273.00
| Professional | | $740.00 | $4,273.00 | $4,273.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.00 / $1,124.00 / $1,124.00
| Facility | | $1,124.00 | $1,124.00 | $1,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.00 / $1,124.00 / $1,649.16
| Professional | | $727.00 | $1,124.00 | $1,649.16 |