- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.29 / $780.29 / $780.29
| Professional | | $780.29 | $780.29 | $780.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.00 / $1,830.00 / $2,287.00
| Professional | | $1,525.00 | $1,830.00 | $2,287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.09 / $1,307.63 / $1,827.20
| Professional | | $1,055.09 | $1,307.63 | $1,827.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.50 / $1,569.98 / $3,030.71
| Professional | | $1,215.50 | $1,569.98 | $3,030.71 |