- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.35 / $945.35 / $945.35
| Professional | | $945.35 | $945.35 | $945.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.00 / $2,245.00 / $3,013.00
| Professional | | $1,871.00 | $2,245.00 | $3,013.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.56 / $1,538.42 / $2,221.73
| Professional | | $1,237.56 | $1,538.42 | $2,221.73 |
- 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
- $1,383.24 / $2,299.11 / $3,670.94
| Professional | | $1,383.24 | $2,299.11 | $3,670.94 |