- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.76 / $712.76 / $712.76
| Professional | | $712.76 | $712.76 | $712.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,549.00 / $2,261.00
| Professional | | $1,291.00 | $1,549.00 | $2,261.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.66 / $1,197.38 / $1,663.32
| Professional | | $967.66 | $1,197.38 | $1,663.32 |
- 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
- $1,122.56 / $1,809.41 / $2,742.95
| Professional | | $1,122.56 | $1,809.41 | $2,742.95 |