- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.58 / $584.58 / $584.58
| Professional | | $584.58 | $584.58 | $584.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.00 / $1,374.00 / $1,718.00
| Professional | | $1,145.00 | $1,374.00 | $1,718.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.21 / $983.15 / $1,353.52
| Professional | | $785.21 | $983.15 | $1,353.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.21 / $1,818.93 / $2,163.21
| Professional | | $915.21 | $1,818.93 | $2,163.21 |