- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.75 / $669.75 / $836.39
| Professional | | $669.75 | $669.75 | $836.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.00 / $1,545.00 / $1,924.00
| Professional | | $1,159.00 | $1,545.00 | $1,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $749.66 / $1,005.02 / $1,439.17
| Professional | | $749.66 | $1,005.02 | $1,439.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.41 / $1,371.01 / $2,473.94
| Professional | | $886.41 | $1,371.01 | $2,473.94 |