- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.81 / $819.81 / $819.81
| Professional | | $819.81 | $819.81 | $819.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.00 / $1,886.00 / $2,263.00
| Professional | | $1,415.00 | $1,886.00 | $2,263.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.75 / $1,067.20 / $1,600.80
| Professional | | $671.75 | $1,067.20 | $1,600.80 |
- 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
- $787.72 / $1,300.20 / $2,346.17
| Professional | | $787.72 | $1,300.20 | $2,346.17 |