- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.50 / $834.50 / $1,163.85
| Professional | | $834.50 | $834.50 | $1,163.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,389.20
| Professional | | $1,000.00 | $1,000.00 | $1,389.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,447.20 / $1,447.20 / $2,193.12
| Facility | | $1,447.20 | $1,447.20 | $2,193.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.41 / $1,164.83 / $1,693.30
| Professional | | $498.41 | $1,164.83 | $1,693.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.08 / $1,323.08 / $1,602.25
| Professional | | $1,323.08 | $1,323.08 | $1,602.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.50 / $934.90 / $1,163.85
| Professional | | $834.50 | $934.90 | $1,163.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.40 / $585.32 / $1,417.22
| Professional | | $561.40 | $585.32 | $1,417.22 |