- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.48 / $959.48 / $959.48
| Professional | | $959.48 | $959.48 | $959.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.00 / $2,210.00 / $2,652.00
| Professional | | $1,657.00 | $2,210.00 | $2,652.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.35 / $1,215.86 / $1,823.81
| Professional | | $806.35 | $1,215.86 | $1,823.81 |
- 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
- $946.89 / $1,602.47 / $2,844.21
| Professional | | $946.89 | $1,602.47 | $2,844.21 |