- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.48 / $1,026.48 / $5,529.09
| Professional | | $1,026.48 | $1,026.48 | $5,529.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.47 / $796.53 / $1,546.35
| Professional | | $229.47 | $796.53 | $1,546.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.17 / $779.42 / $1,545.11
| Facility | | $219.17 | $779.42 | $1,545.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.32 / $623.54 / $1,367.14
| Professional | | $243.32 | $623.54 | $1,367.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,680.00 / $1,680.00 / $1,680.00
| Facility | | $1,680.00 | $1,680.00 | $1,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.94 / $1,783.50 / $2,622.80
| Professional | | $1,277.94 | $1,783.50 | $2,622.80 |