- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.11 / $805.11 / $805.11
| Professional | | $805.11 | $805.11 | $805.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,782.00 / $2,674.00
| Professional | | $1,485.00 | $1,782.00 | $2,674.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.97 / $1,333.19 / $1,953.82
| Professional | | $1,036.97 | $1,333.19 | $1,953.82 |
- 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
- $1,160.50 / $1,920.61 / $3,070.30
| Professional | | $1,160.50 | $1,920.61 | $3,070.30 |