- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.24 / $996.24 / $996.24
| Professional | | $996.24 | $996.24 | $996.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.00 / $2,449.00 / $3,943.00
| Professional | | $2,041.00 | $2,449.00 | $3,943.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.43 / $1,657.28 / $1,902.22
| Professional | | $1,098.43 | $1,657.28 | $1,902.22 |
- 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
- $1,044.04 / $2,221.48 / $3,249.86
| Professional | | $1,044.04 | $2,221.48 | $3,249.86 |