- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $812.83 / $812.83
| Professional | | $776.25 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $1,862.09
| Professional | | $630.96 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,122.02
| Professional | | $954.99 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $812.83 / $1,096.48
| Facility | | $109.65 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,479.11
| Professional | | $660.69 | $891.25 | $1,479.11 |