- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $3,090.30
| Professional | | $933.25 | $1,122.02 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,348.96
| Professional | | $1,000.00 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,318.26 / $2,818.38
| Professional | | $954.99 | $1,318.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,698.24
| Professional | | $933.25 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,995.26
| Professional | | $831.76 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $1,380.38
| Professional | | $812.83 | $1,202.26 | $1,380.38 |