- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.89 / $821.89 / $821.89
| Professional | | $821.89 | $821.89 | $821.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.00 / $1,500.00 / $1,800.00
| Professional | | $1,257.00 | $1,500.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.38 / $1,359.64 / $1,857.81
| Professional | | $1,052.38 | $1,359.64 | $1,857.81 |
- 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
- $1,178.66 / $2,543.21 / $3,157.44
| Professional | | $1,178.66 | $2,543.21 | $3,157.44 |