- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.66 / $731.66 / $731.66
| Professional | | $731.66 | $731.66 | $731.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.00 / $1,942.00 / $2,330.00
| Professional | | $1,722.00 | $1,942.00 | $2,330.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.67 / $734.03 / $1,226.51
| Professional | | $681.67 | $734.03 | $1,226.51 |
- 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
- $645.16 / $1,606.16 / $2,315.86
| Professional | | $645.16 | $1,606.16 | $2,315.86 |