- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.46 / $936.46 / $936.46
| Professional | | $936.46 | $936.46 | $936.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.00 / $2,029.00 / $2,962.00
| Professional | | $1,691.00 | $2,029.00 | $2,962.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.73 / $1,567.76 / $2,238.34
| Professional | | $1,272.73 | $1,567.76 | $2,238.34 |
- 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
- $1,482.24 / $1,886.90 / $3,670.94
| Professional | | $1,482.24 | $1,886.90 | $3,670.94 |