- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.48 / $843.48 / $843.48
| Professional | | $843.48 | $843.48 | $843.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.00 / $1,978.00 / $2,472.00
| Professional | | $1,648.00 | $1,978.00 | $2,472.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.21 / $1,413.33 / $2,011.67
| Professional | | $1,150.21 | $1,413.33 | $2,011.67 |
- 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
- $1,316.15 / $2,119.82 / $3,302.64
| Professional | | $1,316.15 | $2,119.82 | $3,302.64 |