- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.49 / $1,216.68 / $2,265.37
| Professional | | $1,015.49 | $1,216.68 | $2,265.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $178.00
| Professional | | $170.00 | $170.00 | $178.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.22 / $736.73 / $1,164.24
| Facility | | $387.22 | $736.73 | $1,164.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.88 / $576.88 / $576.88
| Professional | | $576.88 | $576.88 | $576.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.22 / $732.76 / $1,164.24
| Facility | | $387.22 | $732.76 | $1,164.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.88 / $576.88 / $576.88
| Professional | | $576.88 | $576.88 | $576.88 |