- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.77 / $788.77 / $788.77
| Professional | | $788.77 | $788.77 | $788.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.00 / $1,710.00 / $2,495.00
| Professional | | $1,425.00 | $1,710.00 | $2,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.42 / $1,321.07 / $1,879.16
| Professional | | $1,065.42 | $1,321.07 | $1,879.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.80 / $1,973.74 / $3,065.03
| Professional | | $1,229.80 | $1,973.74 | $3,065.03 |