- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.54 / $863.54 / $1,045.97
| Professional | | $863.54 | $863.54 | $1,045.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.00 / $1,988.00 / $2,400.00
| Professional | | $1,491.00 | $1,988.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.92 / $1,297.50 / $1,834.50
| Professional | | $976.92 | $1,297.50 | $1,834.50 |
- 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
- $1,031.48 / $1,659.95 / $2,908.40
| Professional | | $1,031.48 | $1,659.95 | $2,908.40 |