- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.71 / $989.71 / $989.71
| Professional | | $989.71 | $989.71 | $989.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.00 / $2,434.00 / $3,917.00
| Professional | | $2,028.00 | $2,434.00 | $3,917.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.22 / $1,646.72 / $2,355.10
| Professional | | $1,248.22 | $1,646.72 | $2,355.10 |
- 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
- $1,404.69 / $2,264.25 / $3,839.87
| Professional | | $1,404.69 | $2,264.25 | $3,839.87 |