- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $587.00 / $623.22 / $1,188.92
| Facility | | $587.00 | $623.22 | $1,188.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.22 / $623.22 / $623.22
| Professional | | $623.22 | $623.22 | $623.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $703.60 / $1,188.90
| Professional | | $6.00 | $703.60 | $1,188.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.75 / $9,493.75 / $26,542.00
| Facility | | $1,186.75 | $9,493.75 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,295.00 / $8,295.00 / $8,295.00
| Professional | | $8,295.00 | $8,295.00 | $8,295.00 |