- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.61 / $965.61 / $965.61
| Professional | | $965.61 | $965.61 | $965.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.00 / $2,491.00 / $2,989.00
| Professional | | $2,209.00 | $2,491.00 | $2,989.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.73 / $1,411.91 / $2,314.40
| Professional | | $1,360.73 | $1,411.91 | $2,314.40 |
- 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
- $1,566.40 / $2,209.83 / $3,759.36
| Professional | | $1,566.40 | $2,209.83 | $3,759.36 |