- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.22 / $988.70 / $1,654.98
| Professional | | $825.22 | $988.70 | $1,654.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.00 / $568.00 / $672.00
| Professional | | $104.00 | $568.00 | $672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.00 / $940.30 / $1,350.70
| Professional | | $700.00 | $940.30 | $1,350.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.32 / $2,968.44 / $2,968.44
| Facility | | $1,188.32 | $2,968.44 | $2,968.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,357.89 / $4,357.89 / $4,357.89
| Professional | | $4,357.89 | $4,357.89 | $4,357.89 |