- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.57 / $818.57 / $818.57
| Professional | | $818.57 | $818.57 | $818.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.00 / $2,089.00 / $2,507.00
| Professional | | $1,853.00 | $2,089.00 | $2,507.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.26 / $1,287.78 / $1,977.44
| Professional | | $1,246.26 | $1,287.78 | $1,977.44 |
- 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
- $1,230.67 / $2,692.91 / $3,429.37
| Professional | | $1,230.67 | $2,692.91 | $3,429.37 |