- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.74 / $733.74 / $733.74
| Professional | | $733.74 | $733.74 | $733.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.00 / $1,871.00 / $2,245.00
| Professional | | $1,659.00 | $1,871.00 | $2,245.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.13 / $1,112.33 / $1,768.17
| Professional | | $1,049.13 | $1,112.33 | $1,768.17 |
- 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
- $1,059.20 / $1,855.87 / $2,951.52
| Professional | | $1,059.20 | $1,855.87 | $2,951.52 |