- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.16 / $953.16 / $953.16
| Professional | | $953.16 | $953.16 | $953.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.00 / $1,740.00 / $2,088.00
| Professional | | $1,458.00 | $1,740.00 | $2,088.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.42 / $1,576.03 / $2,186.13
| Professional | | $1,109.42 | $1,576.03 | $2,186.13 |
- 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
- $1,243.00 / $2,124.48 / $3,228.72
| Professional | | $1,243.00 | $2,124.48 | $3,228.72 |