- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.69 / $986.69 / $986.69
| Professional | | $986.69 | $986.69 | $986.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.00 / $2,138.00 / $3,120.00
| Professional | | $1,782.00 | $2,138.00 | $3,120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.47 / $1,622.44 / $2,319.48
| Professional | | $1,352.47 | $1,622.44 | $2,319.48 |
- 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
- $1,514.15 / $3,095.40 / $3,948.10
| Professional | | $1,514.15 | $3,095.40 | $3,948.10 |