- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.12 / $948.12 / $948.12
| Professional | | $948.12 | $948.12 | $948.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.00 / $2,074.00 / $3,110.00
| Professional | | $1,728.00 | $2,074.00 | $3,110.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.02 / $1,550.48 / $2,121.01
| Professional | | $1,221.02 | $1,550.48 | $2,121.01 |
- 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
- $1,365.64 / $2,261.76 / $3,619.44
| Professional | | $1,365.64 | $2,261.76 | $3,619.44 |