- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.23 / $826.23 / $826.23
| Professional | | $826.23 | $826.23 | $826.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.00 / $2,136.00 / $2,563.00
| Professional | | $1,894.00 | $2,136.00 | $2,563.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.78 / $1,248.52 / $1,989.99
| Professional | | $1,186.78 | $1,248.52 | $1,989.99 |
- 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
- $1,395.89 / $2,259.26 / $3,892.68
| Professional | | $1,395.89 | $2,259.26 | $3,892.68 |