- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.97 / $872.97 / $872.97
| Professional | | $872.97 | $872.97 | $872.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.00 / $2,047.00 / $2,558.00
| Professional | | $1,706.00 | $2,047.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.09 / $1,463.09 / $2,056.73
| Professional | | $1,183.09 | $1,463.09 | $2,056.73 |
- 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
- $1,383.80 / $2,211.94 / $3,418.78
| Professional | | $1,383.80 | $2,211.94 | $3,418.78 |