- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.47 / $822.47 / $822.47
| Professional | | $822.47 | $822.47 | $822.47 |
- 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
- $1,055.57 / $1,359.91 / $1,863.18
| Professional | | $1,055.57 | $1,359.91 | $1,863.18 |
- 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
- $1,181.40 / $1,978.72 / $3,160.08
| Professional | | $1,181.40 | $1,978.72 | $3,160.08 |