- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.22 / $898.22 / $898.22
| Professional | | $898.22 | $898.22 | $898.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.00 / $1,948.00 / $2,843.00
| Professional | | $1,623.00 | $1,948.00 | $2,843.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.73 / $1,479.13 / $2,099.33
| Professional | | $1,228.73 | $1,479.13 | $2,099.33 |
- 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
- $1,377.76 / $2,266.73 / $3,589.07
| Professional | | $1,377.76 | $2,266.73 | $3,589.07 |