- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.27 / $768.27 / $768.27
| Professional | | $768.27 | $768.27 | $768.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.00 / $1,983.00 / $2,380.00
| Professional | | $1,758.00 | $1,983.00 | $2,380.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.68 / $1,123.41 / $1,841.45
| Professional | | $1,082.68 | $1,123.41 | $1,841.45 |
- 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
- $1,246.30 / $2,492.60 / $2,991.11
| Professional | | $1,246.30 | $2,492.60 | $2,991.11 |