- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.84 / $943.84 / $943.84
| Professional | | $943.84 | $943.84 | $943.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,800.00 / $3,601.00
| Professional | | $1,500.00 | $1,800.00 | $3,601.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.96 / $1,562.61 / $2,191.58
| Professional | | $1,213.96 | $1,562.61 | $2,191.58 |
- 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
- $1,379.40 / $2,053.10 / $3,756.72
| Professional | | $1,379.40 | $2,053.10 | $3,756.72 |