- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.08 / $1,411.51 / $1,493.53
| Professional | | $1,047.08 | $1,411.51 | $1,493.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $179.64 / $350.87 / $405.72
| Facility | | $179.64 | $350.87 | $405.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.69 / $179.64 / $179.64
| Professional | | $152.69 | $179.64 | $179.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Facility | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.50 / $1,950.00 / $1,950.00
| Professional | | $1,657.50 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.71 / $1,314.73 / $2,270.90
| Professional | | $1,090.71 | $1,314.73 | $2,270.90 |