- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.32 / $565.32 / $565.32
| Professional | | $565.32 | $565.32 | $565.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.00 / $3,040.00 / $3,648.00
| Professional | | $1,880.00 | $3,040.00 | $3,648.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.45 / $888.91 / $1,283.98
| Professional | | $658.45 | $888.91 | $1,283.98 |
- 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
- $651.80 / $1,269.07 / $2,138.50
| Professional | | $651.80 | $1,269.07 | $2,138.50 |