- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.81 / $942.81 / $942.81
| Professional | | $942.81 | $942.81 | $942.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.00 / $2,209.00 / $2,761.00
| Professional | | $1,841.00 | $2,209.00 | $2,761.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.04 / $1,578.04 / $2,266.60
| Professional | | $1,281.04 | $1,578.04 | $2,266.60 |
- 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
- $1,493.25 / $2,387.07 / $3,692.03
| Professional | | $1,493.25 | $2,387.07 | $3,692.03 |