- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.81 / $426.81 / $426.81
| Professional | | $426.81 | $426.81 | $426.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.00 / $1,004.00 / $1,255.00
| Professional | | $837.00 | $1,004.00 | $1,255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.25 / $718.71 / $993.14
| Professional | | $573.25 | $718.71 | $993.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $6,897.94 / $14,634.00
| Facility | | $4,200.00 | $6,897.94 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.00 / $1,076.50 / $1,664.50
| Professional | | $671.00 | $1,076.50 | $1,664.50 |