- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.35 / $875.05 / $1,127.00
| Professional | | $734.35 | $875.05 | $1,127.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.93 / $1,186.81 / $1,511.86
| Professional | | $760.93 | $1,186.81 | $1,511.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.27 / $1,141.35 / $1,442.56
| Facility | | $950.27 | $1,141.35 | $1,442.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,500.00
| Professional | | $30.00 | $30.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.02 / $1,172.96 / $1,298.97
| Professional | | $997.02 | $1,172.96 | $1,298.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.22 / $656.26 / $983.48
| Professional | | $496.22 | $656.26 | $983.48 |