- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.01 / $783.01 / $783.01
| Professional | | $783.01 | $783.01 | $783.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.00 / $2,013.00 / $2,416.00
| Professional | | $1,785.00 | $2,013.00 | $2,416.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.27 / $1,087.72 / $1,845.89
| Professional | | $1,082.27 | $1,087.72 | $1,845.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.50 / $2,522.84 / $3,161.40
| Professional | | $1,215.50 | $2,522.84 | $3,161.40 |