- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $562.34 / $977.24
| Professional | | $512.86 | $562.34 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $1,737.80
| Professional | | $1,096.48 | $1,659.59 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,000.00 / $1,659.59
| Professional | | $616.60 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,380.38 / $3,090.30
| Facility | | $295.12 | $1,380.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,023.29 / $2,041.74
| Professional | | $588.84 | $1,023.29 | $2,041.74 |