- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.80 / $651.80 / $651.80
| Professional | | $651.80 | $651.80 | $651.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,914.00 / $3,094.00 / $3,713.00
| Professional | | $1,914.00 | $3,094.00 | $3,713.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.30 / $908.96 / $1,312.94
| Professional | | $673.30 | $908.96 | $1,312.94 |
- 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
- $671.70 / $1,440.11 / $2,186.59
| Professional | | $671.70 | $1,440.11 | $2,186.59 |