- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.31 / $336.31 / $876.51
| Professional | | $336.31 | $336.31 | $876.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.00 / $922.00 / $2,125.00
| Professional | | $768.00 | $922.00 | $2,125.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.96 / $788.36 / $2,039.17
| Professional | | $479.96 | $788.36 | $2,039.17 |
- 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
- $1,278.05 / $2,799.18 / $3,989.05
| Professional | | $1,278.05 | $2,799.18 | $3,989.05 |