- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.64 / $979.64 / $979.64
| Professional | | $979.64 | $979.64 | $979.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.00 / $2,530.00 / $3,036.00
| Professional | | $2,244.00 | $2,530.00 | $3,036.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.30 / $1,451.14 / $2,340.48
| Professional | | $1,368.30 | $1,451.14 | $2,340.48 |
- 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
- $1,527.35 / $3,194.12 / $3,746.17
| Professional | | $1,527.35 | $3,194.12 | $3,746.17 |