- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.40 / $1,318.24 / $1,623.16
| Professional | | $933.40 | $1,318.24 | $1,623.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.68 / $1,646.68 / $2,100.40
| Professional | | $1,646.68 | $1,646.68 | $2,100.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.56 / $1,350.00 / $3,090.00
| Professional | | $209.56 | $1,350.00 | $3,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.32 / $285.32 / $285.32
| Professional | | $285.32 | $285.32 | $285.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.52 / $1,333.56 / $2,013.82
| Professional | | $1,035.52 | $1,333.56 | $2,013.82 |