- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.63 / $934.63 / $934.63
| Professional | | $934.63 | $934.63 | $934.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.00 / $2,299.00 / $3,701.00
| Professional | | $1,916.00 | $2,299.00 | $3,701.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.19 / $1,197.29 / $1,697.88
| Professional | | $798.19 | $1,197.29 | $1,697.88 |
- 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
- $1,307.34 / $2,614.69 / $3,606.25
| Professional | | $1,307.34 | $2,614.69 | $3,606.25 |