- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $794.33 / $1,584.89
| Professional | | $575.44 | $794.33 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $831.76 / $1,023.29
| Professional | | $512.86 | $831.76 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $1,258.93
| Facility | | $1,023.29 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $1,258.93
| Professional | | $1,023.29 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $851.14 / $1,230.27
| Facility | | $645.65 | $851.14 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $831.76 / $1,288.25
| Professional | | $79.43 | $831.76 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,174.90
| Professional | | $794.33 | $1,000.00 | $1,174.90 |