- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.13 / $925.13 / $925.13
| Professional | | $925.13 | $925.13 | $925.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.00 / $2,047.00 / $3,071.00
| Professional | | $1,706.00 | $2,047.00 | $3,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.94 / $1,530.32 / $2,228.81
| Professional | | $1,204.94 | $1,530.32 | $2,228.81 |
- 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
- $1,348.04 / $2,227.73 / $3,556.07
| Professional | | $1,348.04 | $2,227.73 | $3,556.07 |