- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.64 / $432.64 / $432.64
| Professional | | $432.64 | $432.64 | $432.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.00 / $941.00 / $1,374.00
| Professional | | $784.00 | $941.00 | $1,374.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.26 / $728.30 / $1,006.06
| Professional | | $581.26 | $728.30 | $1,006.06 |
- 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
- $671.55 / $1,343.11 / $1,679.05
| Professional | | $671.55 | $1,343.11 | $1,679.05 |