- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.05 / $861.05 / $861.05
| Professional | | $861.05 | $861.05 | $861.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.00 / $1,640.00 / $3,282.00
| Professional | | $1,367.00 | $1,640.00 | $3,282.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.96 / $1,425.95 / $1,995.81
| Professional | | $1,098.96 | $1,425.95 | $1,995.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.44 / $2,506.89 / $3,439.92
| Professional | | $1,253.44 | $2,506.89 | $3,439.92 |