- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.60 / $944.60 / $944.60
| Professional | | $944.60 | $944.60 | $944.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.00 / $2,996.00 / $3,595.00
| Professional | | $1,498.00 | $2,996.00 | $3,595.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.35 / $1,562.59 / $2,123.75
| Professional | | $1,167.35 | $1,562.59 | $2,123.75 |
- 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
- $1,332.10 / $2,270.87 / $3,661.67
| Professional | | $1,332.10 | $2,270.87 | $3,661.67 |