- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.82 / $759.95 / $1,628.40
| Professional | | $737.82 | $759.95 | $1,628.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.00 / $1,652.00 / $1,984.08
| Professional | | $1,652.00 | $1,652.00 | $1,984.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Facility | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.49 / $1,208.78 / $3,123.75
| Professional | | $190.49 | $1,208.78 | $3,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.52 / $269.52 / $269.52
| Professional | | $269.52 | $269.52 | $269.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.68 / $1,134.22 / $1,543.16
| Professional | | $909.68 | $1,134.22 | $1,543.16 |