- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.74 / $1,448.30 / $2,237.34
| Professional | | $1,401.74 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $79.69 / $350.00
| Professional | | $79.69 | $79.69 | $350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,401.74 / $1,448.30 / $2,565.17
| Facility | | $1,401.74 | $1,448.30 | $2,565.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.50 / $52.50 / $52.50
| Professional | | $52.50 | $52.50 | $52.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,997.50 / $2,997.50 / $2,997.50
| Facility | | $2,997.50 | $2,997.50 | $2,997.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,997.50 / $2,997.50 / $2,997.50
| Professional | | $2,997.50 | $2,997.50 | $2,997.50 |