- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,137.96
| Professional | | $1,000.00 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,698.24
| Professional | | $1,071.52 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,862.09
| Facility | | $575.44 | $602.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,187.76
| Professional | | $870.96 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $1,659.59
| Professional | | $912.01 | $1,202.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,096.48
| Facility | | $302.00 | $416.87 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,187.76
| Professional | | $851.14 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $1,548.82
| Professional | | $891.25 | $1,348.96 | $1,548.82 |