- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.78 / $931.78 / $931.78
| Professional | | $931.78 | $931.78 | $931.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.00 / $2,020.00 / $2,948.00
| Professional | | $1,683.00 | $2,020.00 | $2,948.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.56 / $1,560.92 / $2,273.06
| Professional | | $1,412.56 | $1,560.92 | $2,273.06 |
- 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
- $1,596.65 / $2,905.92 / $3,895.32
| Professional | | $1,596.65 | $2,905.92 | $3,895.32 |