- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.15 / $985.15 / $985.15
| Professional | | $985.15 | $985.15 | $985.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,835.00 / $4,583.00 / $5,500.00
| Professional | | $2,835.00 | $4,583.00 | $5,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.18 / $1,159.89 / $1,675.40
| Professional | | $859.18 | $1,159.89 | $1,675.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $7,542.00 / $14,634.00
| Facility | | $4,200.00 | $7,542.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.51 / $1,783.11 / $2,797.58
| Professional | | $891.51 | $1,783.11 | $2,797.58 |