- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.16 / $735.16 / $735.16
| Professional | | $735.16 | $735.16 | $735.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.00 / $1,648.00 / $2,059.00
| Professional | | $1,373.00 | $1,648.00 | $2,059.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.29 / $1,177.79 / $1,633.28
| Professional | | $944.29 | $1,177.79 | $1,633.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.58 / $1,744.65 / $2,715.23
| Professional | | $1,084.58 | $1,744.65 | $2,715.23 |