- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.28 / $797.28 / $797.28
| Professional | | $797.28 | $797.28 | $797.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.00 / $1,736.00 / $2,534.00
| Professional | | $1,447.00 | $1,736.00 | $2,534.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.30 / $1,319.69 / $1,873.07
| Professional | | $1,087.30 | $1,319.69 | $1,873.07 |
- 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
- $1,220.45 / $2,492.34 / $3,174.58
| Professional | | $1,220.45 | $2,492.34 | $3,174.58 |