- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.04 / $730.04 / $730.04
| Professional | | $730.04 | $730.04 | $730.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.00 / $1,548.00 / $2,258.00
| Professional | | $1,290.00 | $1,548.00 | $2,258.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.84 / $1,200.86 / $1,700.55
| Professional | | $882.84 | $1,200.86 | $1,700.55 |
- 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
- $800.08 / $2,204.34 / $2,814.23
| Professional | | $800.08 | $2,204.34 | $2,814.23 |