- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $851.14
| Professional | | $549.54 | $676.08 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $851.14 / $870.96
| Professional | | $758.58 | $851.14 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,230.27
| Facility | | $812.83 | $812.83 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $812.83 / $1,445.44
| Professional | | $93.33 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,148.15 / $1,862.09
| Professional | | $1,122.02 | $1,148.15 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $446.68 / $794.33
| Facility | | $52.48 | $446.68 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $588.84 / $1,000.00
| Professional | | $102.33 | $588.84 | $1,000.00 |