- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.84 / $901.84 / $901.84
| Professional | | $901.84 | $901.84 | $901.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.00 / $2,114.00 / $2,642.00
| Professional | | $1,762.00 | $2,114.00 | $2,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.28 / $1,510.26 / $2,112.25
| Professional | | $1,225.28 | $1,510.26 | $2,112.25 |
- 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
- $1,090.93 / $2,283.33 / $3,532.33
| Professional | | $1,090.93 | $2,283.33 | $3,532.33 |