- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.06 / $962.06 / $962.06
| Professional | | $962.06 | $962.06 | $962.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,487.00 / $2,984.00
| Professional | | $2,205.00 | $2,487.00 | $2,984.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.39 / $1,360.75 / $2,295.51
| Professional | | $1,348.39 | $1,360.75 | $2,295.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,732.00 / $12,732.00 / $31,027.00
| Facility | | $12,732.00 | $12,732.00 | $31,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.19 / $3,044.79 / $3,916.46
| Professional | | $1,167.19 | $3,044.79 | $3,916.46 |