- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.45 / $947.45 / $4,014.43
| Professional | | $947.45 | $947.45 | $4,014.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.34 / $619.79 / $1,159.76
| Professional | | $213.34 | $619.79 | $1,159.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.36 / $591.79 / $1,173.18
| Facility | | $204.36 | $591.79 | $1,173.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.88 / $473.43 / $1,019.10
| Professional | | $226.88 | $473.43 | $1,019.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,680.00 / $1,680.00 / $1,680.00
| Facility | | $1,680.00 | $1,680.00 | $1,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.55 / $1,338.75 / $1,966.10
| Professional | | $945.55 | $1,338.75 | $1,966.10 |