- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.82 / $820.82 / $820.82
| Professional | | $820.82 | $820.82 | $820.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.00 / $2,093.00 / $2,512.00
| Professional | | $1,856.00 | $2,093.00 | $2,512.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.61 / $1,325.39 / $1,964.44
| Professional | | $1,174.61 | $1,325.39 | $1,964.44 |
- 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
- $1,496.68 / $2,700.72 / $4,615.92
| Professional | | $1,496.68 | $2,700.72 | $4,615.92 |