- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.02 / $835.02 / $835.02
| Professional | | $835.02 | $835.02 | $835.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.00 / $1,848.00 / $2,772.00
| Professional | | $1,540.00 | $1,848.00 | $2,772.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.97 / $1,381.93 / $1,858.13
| Professional | | $1,083.97 | $1,381.93 | $1,858.13 |
- 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
- $1,213.31 / $2,003.62 / $3,197.04
| Professional | | $1,213.31 | $2,003.62 | $3,197.04 |