- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.15 / $819.15 / $819.15
| Professional | | $819.15 | $819.15 | $819.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.00 / $2,089.00 / $2,507.00
| Professional | | $1,852.00 | $2,089.00 | $2,507.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.95 / $1,192.66 / $1,964.52
| Professional | | $1,173.95 | $1,192.66 | $1,964.52 |
- 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
- $1,324.95 / $2,702.95 / $3,364.69
| Professional | | $1,324.95 | $2,702.95 | $3,364.69 |