- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.66 / $737.66 / $895.53
| Professional | | $737.66 | $737.66 | $895.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.00 / $1,695.00 / $2,054.00
| Professional | | $1,271.00 | $1,695.00 | $2,054.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.05 / $1,108.22 / $1,613.30
| Professional | | $839.05 | $1,108.22 | $1,613.30 |
- 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
- $820.91 / $1,494.00 / $2,633.78
| Professional | | $820.91 | $1,494.00 | $2,633.78 |