- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.87 / $941.87 / $941.87
| Professional | | $941.87 | $941.87 | $941.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.00 / $2,033.00 / $2,968.00
| Professional | | $1,694.00 | $2,033.00 | $2,968.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.09 / $1,543.43 / $2,223.40
| Professional | | $1,260.09 | $1,543.43 | $2,223.40 |
- 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
- $1,409.65 / $2,358.03 / $3,744.85
| Professional | | $1,409.65 | $2,358.03 | $3,744.85 |