- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.01 / $935.01 / $935.01
| Professional | | $935.01 | $935.01 | $935.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.00 / $2,409.00 / $2,891.00
| Professional | | $2,136.00 | $2,409.00 | $2,891.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.68 / $1,414.54 / $2,240.07
| Professional | | $1,346.68 | $1,414.54 | $2,240.07 |
- 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
- $1,226.88 / $3,071.05 / $3,940.19
| Professional | | $1,226.88 | $3,071.05 | $3,940.19 |