- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.91 / $967.91 / $967.91
| Professional | | $967.91 | $967.91 | $967.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.00 / $2,098.00 / $3,062.00
| Professional | | $1,748.00 | $2,098.00 | $3,062.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.06 / $1,620.39 / $2,263.77
| Professional | | $1,313.06 | $1,620.39 | $2,263.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.50 / $2,465.10 / $3,798.95
| Professional | | $1,545.50 | $2,465.10 | $3,798.95 |