- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.28 / $387.28 / $528.82
| Professional | | $387.28 | $387.28 | $528.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.00 / $942.00 / $1,375.00
| Professional | | $700.00 | $942.00 | $1,375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.13 / $766.24 / $1,309.27
| Professional | | $557.13 | $766.24 | $1,309.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.00 / $1,308.98 / $2,262.46
| Professional | | $814.00 | $1,308.98 | $2,262.46 |