- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.78 / $898.78 / $898.78
| Professional | | $898.78 | $898.78 | $898.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.00 / $2,107.00 / $2,635.00
| Professional | | $1,756.00 | $2,107.00 | $2,635.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.04 / $1,505.98 / $2,102.67
| Professional | | $1,216.04 | $1,505.98 | $2,102.67 |
- 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
- $1,372.80 / $2,288.31 / $3,468.97
| Professional | | $1,372.80 | $2,288.31 | $3,468.97 |