- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $870.96
| Professional | | $457.09 | $512.86 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $1,548.82
| Professional | | $1,000.00 | $1,513.56 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $1,513.56
| Professional | | $549.54 | $912.01 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $3,090.30
| Facility | | $204.17 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $912.01 / $1,819.70
| Professional | | $524.81 | $912.01 | $1,819.70 |