- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.70 / $935.70 / $935.70
| Professional | | $935.70 | $935.70 | $935.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.00 / $2,412.00 / $2,894.00
| Professional | | $2,139.00 | $2,412.00 | $2,894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.18 / $1,433.00 / $2,485.27
| Professional | | $1,348.18 | $1,433.00 | $2,485.27 |
- 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
- $1,598.86 / $3,074.39 / $3,967.92
| Professional | | $1,598.86 | $3,074.39 | $3,967.92 |