- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.44 / $817.44 / $817.44
| Professional | | $817.44 | $817.44 | $817.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.00 / $1,770.00 / $2,584.00
| Professional | | $1,475.00 | $1,770.00 | $2,584.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.15 / $1,344.53 / $1,923.05
| Professional | | $1,126.15 | $1,344.53 | $1,923.05 |
- 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
- $1,264.45 / $2,052.60 / $3,247.18
| Professional | | $1,264.45 | $2,052.60 | $3,247.18 |