- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.76 / $712.76 / $829.59
| Professional | | $712.76 | $712.76 | $829.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.00 / $1,642.00 / $1,911.00
| Professional | | $1,232.00 | $1,642.00 | $1,911.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.81 / $1,060.23 / $1,498.71
| Professional | | $826.81 | $1,060.23 | $1,498.71 |
- 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
- $920.06 / $1,393.25 / $2,445.29
| Professional | | $920.06 | $1,393.25 | $2,445.29 |