- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.35 / $841.35 / $841.35
| Professional | | $841.35 | $841.35 | $841.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.00 / $1,970.00 / $2,462.00
| Professional | | $1,642.00 | $1,970.00 | $2,462.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.23 / $1,407.87 / $1,969.00
| Professional | | $1,138.23 | $1,407.87 | $1,969.00 |
- 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
- $1,284.25 / $2,071.67 / $3,245.86
| Professional | | $1,284.25 | $2,071.67 | $3,245.86 |