- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.72 / $818.72 / $818.72
| Professional | | $818.72 | $818.72 | $818.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.00 / $1,777.00 / $2,594.00
| Professional | | $1,481.00 | $1,777.00 | $2,594.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.30 / $1,373.57 / $2,004.08
| Professional | | $1,107.30 | $1,373.57 | $2,004.08 |
- 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
- $1,304.05 / $2,118.98 / $3,210.22
| Professional | | $1,304.05 | $2,118.98 | $3,210.22 |