- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.17 / $639.17 / $639.17
| Professional | | $639.17 | $639.17 | $639.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.00 / $1,500.00 / $1,876.00
| Professional | | $1,250.00 | $1,500.00 | $1,876.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.34 / $1,072.96 / $1,493.26
| Professional | | $860.34 | $1,072.96 | $1,493.26 |
- 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
- $974.05 / $1,634.28 / $2,618.90
| Professional | | $974.05 | $1,634.28 | $2,618.90 |