- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.85 / $576.85 / $576.85
| Professional | | $576.85 | $576.85 | $576.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.00 / $1,490.00 / $1,788.00
| Professional | | $1,321.00 | $1,490.00 | $1,788.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.90 / $874.36 / $1,386.11
| Professional | | $827.90 | $874.36 | $1,386.11 |
- 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
- $978.45 / $1,885.14 / $2,544.94
| Professional | | $978.45 | $1,885.14 | $2,544.94 |