- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.81 / $914.81 / $914.81
| Facility | | $914.81 | $914.81 | $914.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.00 / $896.80 / $1,004.88
| Professional | | $795.00 | $896.80 | $1,004.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,077.00 / $4,117.77 / $5,096.25
| Professional | | $4,077.00 | $4,117.77 | $5,096.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.72 / $914.81 / $2,744.43
| Facility | | $158.72 | $914.81 | $2,744.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.58 / $77.16 / $3,117.96
| Professional | | $38.58 | $77.16 | $3,117.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.58 / $77.16 / $2,650.26
| Professional | | $38.58 | $77.16 | $2,650.26 |