- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.31 / $976.31 / $976.31
| Professional | | $976.31 | $976.31 | $976.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,231.00 / $2,516.00 / $3,019.00
| Professional | | $2,231.00 | $2,516.00 | $3,019.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.92 / $1,468.08 / $2,357.28
| Professional | | $1,406.92 | $1,468.08 | $2,357.28 |
- 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
- $1,635.15 / $3,208.66 / $4,102.57
| Professional | | $1,635.15 | $3,208.66 | $4,102.57 |