- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.68 / $901.68 / $901.68
| Professional | | $901.68 | $901.68 | $901.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.00 / $1,648.00 / $1,978.00
| Professional | | $1,381.00 | $1,648.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.61 / $1,484.37 / $2,165.42
| Professional | | $1,158.61 | $1,484.37 | $2,165.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.08 / $1,794.49 / $3,044.58
| Professional | | $1,288.08 | $1,794.49 | $3,044.58 |