- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.77 / $844.77 / $844.77
| Professional | | $844.77 | $844.77 | $844.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.00 / $1,830.00 / $2,670.00
| Professional | | $1,525.00 | $1,830.00 | $2,670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.69 / $1,388.35 / $1,986.28
| Professional | | $1,162.69 | $1,388.35 | $1,986.28 |
- 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
- $1,302.40 / $2,138.07 / $3,380.51
| Professional | | $1,302.40 | $2,138.07 | $3,380.51 |