- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.67 / $717.67 / $1,461.43
| Professional | | $717.67 | $717.67 | $1,461.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,629.87 / $1,629.87 / $1,629.87
| Facility | | $1,629.87 | $1,629.87 | $1,629.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.87 / $1,629.87 / $1,629.87
| Professional | | $1,629.87 | $1,629.87 | $1,629.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.00 / $120.00 / $1,803.48
| Facility | | $120.00 | $120.00 | $1,803.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $120.00
| Professional | | $102.00 | $102.00 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.50 / $69.12 / $79.92
| Professional | | $68.50 | $69.12 | $79.92 |