- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.97 / $745.97 / $813.68
| Professional | | $745.97 | $745.97 | $813.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.00 / $1,718.00 / $1,876.00
| Professional | | $1,288.00 | $1,718.00 | $1,876.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.40 / $922.75 / $1,278.83
| Professional | | $721.40 | $922.75 | $1,278.83 |
- 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
- $779.24 / $1,383.61 / $2,302.30
| Professional | | $779.24 | $1,383.61 | $2,302.30 |