- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.85 / $744.85 / $744.85
| Professional | | $744.85 | $744.85 | $744.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.00 / $1,618.00 / $2,362.00
| Professional | | $1,348.00 | $1,618.00 | $2,362.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.90 / $1,250.43 / $1,759.41
| Professional | | $1,007.90 | $1,250.43 | $1,759.41 |
- 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
- $1,159.40 / $1,862.52 / $2,896.06
| Professional | | $1,159.40 | $1,862.52 | $2,896.06 |