- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.98 / $860.98 / $860.98
| Professional | | $860.98 | $860.98 | $860.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.00 / $1,572.00 / $1,886.00
| Professional | | $1,317.00 | $1,572.00 | $1,886.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.38 / $1,424.49 / $1,835.40
| Professional | | $1,101.38 | $1,424.49 | $1,835.40 |
- 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
- $1,232.00 / $2,669.91 / $3,307.91
| Professional | | $1,232.00 | $2,669.91 | $3,307.91 |