- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.11 / $704.11 / $704.11
| Professional | | $704.11 | $704.11 | $704.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.00 / $1,528.00 / $2,230.00
| Professional | | $1,273.00 | $1,528.00 | $2,230.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.86 / $1,180.78 / $1,646.32
| Professional | | $952.86 | $1,180.78 | $1,646.32 |
- 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
- $1,117.59 / $1,787.81 / $2,762.77
| Professional | | $1,117.59 | $1,787.81 | $2,762.77 |