- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.96 / $984.96 / $984.96
| Professional | | $984.96 | $984.96 | $984.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.00 / $2,537.00 / $3,044.00
| Professional | | $2,250.00 | $2,537.00 | $3,044.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.51 / $1,624.60 / $2,676.61
| Professional | | $1,507.51 | $1,624.60 | $2,676.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.57 / $3,231.04 / $4,366.54
| Professional | | $1,295.57 | $3,231.04 | $4,366.54 |