- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.35 / $1,074.18 / $1,632.21
| Professional | | $859.35 | $1,074.18 | $1,632.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,337.58 / $1,337.58
| Professional | | $150.00 | $1,337.58 | $1,337.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $672.51 / $976.62 / $1,364.58
| Facility | | $672.51 | $976.62 | $1,364.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.76 / $1,124.11 / $2,955.00
| Professional | | $737.76 | $1,124.11 | $2,955.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.00 / $948.00 / $948.00
| Facility | | $948.00 | $948.00 | $948.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.76 / $948.00 / $1,184.44
| Professional | | $737.76 | $948.00 | $1,184.44 |