- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.69 / $728.69 / $898.14
| Professional | | $728.69 | $728.69 | $898.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.00 / $1,672.00 / $2,055.00
| Professional | | $1,254.00 | $1,672.00 | $2,055.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.20 / $1,092.15 / $1,563.63
| Professional | | $821.20 | $1,092.15 | $1,563.63 |
- 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
- $993.52 / $1,477.81 / $2,666.67
| Professional | | $993.52 | $1,477.81 | $2,666.67 |