- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.43 / $960.43 / $960.43
| Professional | | $960.43 | $960.43 | $960.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.00 / $2,215.00 / $2,770.00
| Professional | | $1,846.00 | $2,215.00 | $2,770.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.69 / $1,582.92 / $2,245.44
| Professional | | $1,295.69 | $1,582.92 | $2,245.44 |
- 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
- $1,496.00 / $1,928.69 / $3,535.99
| Professional | | $1,496.00 | $1,928.69 | $3,535.99 |