- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $1,819.70
| Professional | | $1,318.26 | $1,548.82 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $1,698.24
| Professional | | $1,380.38 | $1,513.56 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,187.76 / $2,818.38
| Professional | | $1,905.46 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,445.44
| Facility | | $794.33 | $794.33 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $851.14 / $1,548.82
| Professional | | $794.33 | $851.14 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | | $954.99 | $954.99 | $954.99 |