- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.45 / $713.45 / $713.45
| Professional | | $713.45 | $713.45 | $713.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.00 / $1,552.00 / $2,264.00
| Professional | | $1,293.00 | $1,552.00 | $2,264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.16 / $1,199.09 / $1,701.19
| Professional | | $962.16 | $1,199.09 | $1,701.19 |
- 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
- $1,111.00 / $1,785.32 / $2,773.32
| Professional | | $1,111.00 | $1,785.32 | $2,773.32 |