- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.54 / $820.54 / $820.54
| Professional | | $820.54 | $820.54 | $820.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.00 / $1,888.00 / $2,266.00
| Professional | | $1,416.00 | $1,888.00 | $2,266.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.86 / $1,056.20 / $1,584.30
| Professional | | $670.86 | $1,056.20 | $1,584.30 |
- 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
- $801.35 / $1,368.00 / $2,468.52
| Professional | | $801.35 | $1,368.00 | $2,468.52 |