- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.62 / $923.62 / $923.62
| Professional | | $923.62 | $923.62 | $923.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.00 / $2,384.00 / $2,861.00
| Professional | | $2,115.00 | $2,384.00 | $2,861.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.41 / $1,350.21 / $2,205.35
| Professional | | $1,304.41 | $1,350.21 | $2,205.35 |
- 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
- $1,294.61 / $2,268.40 / $3,552.91
| Professional | | $1,294.61 | $2,268.40 | $3,552.91 |