- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.80 / $941.73 / $1,060.53
| Professional | | $718.80 | $941.73 | $1,060.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.00 / $1,712.00 / $1,712.00
| Professional | | $1,712.00 | $1,712.00 | $1,712.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.00 / $2,490.69 / $3,112.80
| Facility | | $1,274.00 | $2,490.69 | $3,112.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.68 / $1,388.90 / $2,131.62
| Professional | | $1,073.68 | $1,388.90 | $2,131.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,118.00 / $2,118.00 / $8,045.72
| Facility | | $2,118.00 | $2,118.00 | $8,045.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.09 / $931.86 / $1,852.72
| Professional | | $661.09 | $931.86 | $1,852.72 |