- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.36 / $809.36 / $809.36
| Professional | | $809.36 | $809.36 | $809.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.00 / $1,789.00 / $2,684.00
| Professional | | $1,491.00 | $1,789.00 | $2,684.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.58 / $1,339.96 / $1,704.66
| Professional | | $986.58 | $1,339.96 | $1,704.66 |
- 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 / $1,803.60 / $2,819.51
| Professional | | $1,117.59 | $1,803.60 | $2,819.51 |