- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.50 / $825.68 / $1,021.88
| Professional | | $817.50 | $825.68 | $1,021.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $762.61 / $762.61
| Professional | | $150.00 | $762.61 | $762.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.52 / $1,065.60 / $1,065.60
| Facility | | $1,029.52 | $1,065.60 | $1,065.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.52 / $1,029.52 / $2,137.79
| Professional | | $1,029.52 | $1,029.52 | $2,137.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,029.52 / $1,029.52 / $1,029.52
| Facility | | $1,029.52 | $1,029.52 | $1,029.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.52 / $1,029.52 / $1,029.52
| Professional | | $1,029.52 | $1,029.52 | $1,029.52 |