- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.79 / $562.79 / $562.79
| Professional | | $562.79 | $562.79 | $562.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.00 / $1,250.00 / $1,876.00
| Professional | | $1,042.00 | $1,250.00 | $1,876.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.76 / $942.58 / $1,222.39
| Professional | | $707.76 | $942.58 | $1,222.39 |
- 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
- $812.90 / $1,309.74 / $2,038.08
| Professional | | $812.90 | $1,309.74 | $2,038.08 |