- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.96 / $781.96 / $781.96
| Professional | | $781.96 | $781.96 | $781.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.00 / $1,696.00 / $2,474.00
| Professional | | $1,413.00 | $1,696.00 | $2,474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.95 / $1,309.77 / $1,808.87
| Professional | | $1,056.95 | $1,309.77 | $1,808.87 |
- 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
- $1,244.08 / $1,752.04 / $3,063.71
| Professional | | $1,244.08 | $1,752.04 | $3,063.71 |