- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.98 / $993.21 / $1,662.53
| Professional | | $828.98 | $993.21 | $1,662.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.00 / $573.00 / $676.00
| Professional | | $104.00 | $573.00 | $676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.00 / $905.90 / $1,361.10
| Professional | | $700.00 | $905.90 | $1,361.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.32 / $2,771.52 / $2,771.52
| Facility | | $1,188.32 | $2,771.52 | $2,771.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,772.97 / $3,772.97 / $3,772.97
| Professional | | $3,772.97 | $3,772.97 | $3,772.97 |