- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.85 / $715.85 / $870.91
| Professional | | $715.85 | $715.85 | $870.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.00 / $1,648.00 / $2,002.00
| Professional | | $1,236.00 | $1,648.00 | $2,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.08 / $1,081.42 / $1,535.62
| Professional | | $811.08 | $1,081.42 | $1,535.62 |
- 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
- $928.46 / $1,448.40 / $2,407.91
| Professional | | $928.46 | $1,448.40 | $2,407.91 |