- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.59 / $1,369.70 / $1,708.16
| Professional | | $638.59 | $1,369.70 | $1,708.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.08 / $1,962.71 / $2,310.00
| Professional | | $731.08 | $1,962.71 | $2,310.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.11 / $1,708.16 / $2,562.23
| Facility | | $1,281.11 | $1,708.16 | $2,562.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.60 / $2,612.48 / $4,421.12
| Professional | | $2,009.60 | $2,612.48 | $4,421.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.34 / $771.56 / $1,106.90
| Professional | | $697.34 | $771.56 | $1,106.90 |