- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.88 / $723.88 / $723.88
| Professional | | $723.88 | $723.88 | $723.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.00 / $3,421.00 / $4,105.00
| Professional | | $2,116.00 | $3,421.00 | $4,105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.68 / $997.21 / $1,440.42
| Professional | | $738.68 | $997.21 | $1,440.42 |
- 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
- $711.50 / $1,427.89 / $2,384.19
| Professional | | $711.50 | $1,427.89 | $2,384.19 |