- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.41 / $948.41 / $948.41
| Professional | | $948.41 | $948.41 | $948.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.00 / $2,224.00 / $2,779.00
| Professional | | $1,853.00 | $2,224.00 | $2,779.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.15 / $1,588.35 / $2,257.92
| Professional | | $1,286.15 | $1,588.35 | $2,257.92 |
- 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
- $1,491.60 / $2,387.91 / $3,701.26
| Professional | | $1,491.60 | $2,387.91 | $3,701.26 |