- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.60 / $845.60 / $845.60
| Professional | | $845.60 | $845.60 | $845.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.00 / $1,871.00 / $2,807.00
| Professional | | $1,559.00 | $1,871.00 | $2,807.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.31 / $1,402.07 / $1,881.83
| Professional | | $1,097.31 | $1,402.07 | $1,881.83 |
- 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
- $1,240.80 / $2,031.00 / $3,214.22
| Professional | | $1,240.80 | $2,031.00 | $3,214.22 |