- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.34 / $839.34 / $1,030.54
| Professional | | $839.34 | $839.34 | $1,030.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.00 / $1,928.00 / $2,360.00
| Professional | | $1,446.00 | $1,928.00 | $2,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.93 / $1,260.60 / $1,819.09
| Professional | | $949.93 | $1,260.60 | $1,819.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.48 / $1,701.60 / $3,070.50
| Professional | | $1,162.48 | $1,701.60 | $3,070.50 |