- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.38 / $339.38 / $1,357.84
| Professional | | $339.38 | $339.38 | $1,357.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.00 / $928.00 / $3,272.00
| Professional | | $773.00 | $928.00 | $3,272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.83 / $856.43 / $3,665.71
| Professional | | $515.83 | $856.43 | $3,665.71 |
- 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
- $2,373.98 / $4,283.80 / $6,952.44
| Professional | | $2,373.98 | $4,283.80 | $6,952.44 |