- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $794.33
| Professional | | $630.96 | $630.96 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $912.01
| Professional | | $151.36 | $151.36 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $1,000.00
| Facility | | $588.84 | $645.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $4,168.69
| Professional | | $588.84 | $645.65 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Professional | | $645.65 | $645.65 | $645.65 |