- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.82 / $712.82 / $712.82
| Professional | | $712.82 | $712.82 | $712.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.00 / $1,544.00 / $2,255.00
| Professional | | $1,287.00 | $1,544.00 | $2,255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.34 / $1,173.61 / $1,677.65
| Professional | | $981.34 | $1,173.61 | $1,677.65 |
- 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
- $1,101.10 / $1,807.75 / $2,852.51
| Professional | | $1,101.10 | $1,807.75 | $2,852.51 |