- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.88 / $1,910.64 / $3,107.65
| Professional | | $1,586.88 | $1,910.64 | $3,107.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.00 / $576.00 / $576.00
| Professional | | $529.00 | $576.00 | $576.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.70 / $380.00 / $968.60
| Professional | | $359.70 | $380.00 | $968.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.11 / $5,414.80 / $12,000.00
| Facility | | $1,154.11 | $5,414.80 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.35 / $2,058.35 / $2,058.35
| Professional | | $2,058.35 | $2,058.35 | $2,058.35 |