- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.34 / $932.34 / $932.34
| Professional | | $932.34 | $932.34 | $932.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.00 / $2,064.00 / $3,096.00
| Professional | | $1,720.00 | $2,064.00 | $3,096.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.91 / $1,543.34 / $2,072.88
| Professional | | $1,209.91 | $1,543.34 | $2,072.88 |
- 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
- $1,353.55 / $2,875.62 / $3,581.16
| Professional | | $1,353.55 | $2,875.62 | $3,581.16 |