- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.91 / $558.91 / $558.91
| Professional | | $558.91 | $558.91 | $558.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.00 / $1,218.00 / $1,778.00
| Professional | | $1,015.00 | $1,218.00 | $1,778.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.16 / $934.33 / $1,321.10
| Professional | | $767.16 | $934.33 | $1,321.10 |
- 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
- $1,232.23 / $2,151.81 / $4,062.93
| Professional | | $1,232.23 | $2,151.81 | $4,062.93 |