- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.11 / $982.11 / $982.11
| Professional | | $982.11 | $982.11 | $982.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.00 / $2,300.00 / $2,875.00
| Professional | | $1,917.00 | $2,300.00 | $2,875.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.49 / $1,643.41 / $2,405.61
| Professional | | $1,331.49 | $1,643.41 | $2,405.61 |
- 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
- $1,199.88 / $1,974.66 / $3,686.81
| Professional | | $1,199.88 | $1,974.66 | $3,686.81 |