- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.02 / $968.02 / $968.02
| Professional | | $968.02 | $968.02 | $968.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,190.00 / $2,470.00 / $2,964.00
| Professional | | $2,190.00 | $2,470.00 | $2,964.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.56 / $1,468.50 / $2,338.75
| Professional | | $1,384.56 | $1,468.50 | $2,338.75 |
- 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
- $1,398.36 / $3,185.16 / $3,896.64
| Professional | | $1,398.36 | $3,185.16 | $3,896.64 |