- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.27 / $917.27 / $917.27
| Professional | | $917.27 | $917.27 | $917.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.00 / $1,984.00 / $2,896.00
| Professional | | $1,653.00 | $1,984.00 | $2,896.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.19 / $1,506.14 / $2,148.94
| Professional | | $1,251.19 | $1,506.14 | $2,148.94 |
- 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
- $1,401.95 / $2,304.90 / $3,664.31
| Professional | | $1,401.95 | $2,304.90 | $3,664.31 |