- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.41 / $931.41 / $931.41
| Professional | | $931.41 | $931.41 | $931.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.00 / $2,400.00 / $2,880.00
| Professional | | $2,128.00 | $2,400.00 | $2,880.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.13 / $1,547.07 / $2,263.25
| Professional | | $1,418.13 | $1,547.07 | $2,263.25 |
- 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
- $1,586.19 / $3,048.66 / $3,855.73
| Professional | | $1,586.19 | $3,048.66 | $3,855.73 |