- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.84 / $705.84 / $705.84
| Professional | | $705.84 | $705.84 | $705.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.00 / $1,658.00 / $2,074.00
| Professional | | $1,382.00 | $1,658.00 | $2,074.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.43 / $1,186.08 / $1,733.77
| Professional | | $989.43 | $1,186.08 | $1,733.77 |
- 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
- $1,112.65 / $1,825.17 / $2,860.42
| Professional | | $1,112.65 | $1,825.17 | $2,860.42 |