- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.71 / $839.71 / $839.71
| Professional | | $839.71 | $839.71 | $839.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.00 / $2,160.00 / $2,592.00
| Professional | | $1,915.00 | $2,160.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.02 / $1,174.74 / $1,971.90
| Professional | | $1,169.02 | $1,174.74 | $1,971.90 |
- 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
- $1,023.19 / $2,635.59 / $3,310.55
| Professional | | $1,023.19 | $2,635.59 | $3,310.55 |