- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $2,089.30
| Professional | | $1,000.00 | $1,174.90 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $3,715.35
| Facility | | $1,548.82 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $2,754.23
| Professional | | $1,122.02 | $1,122.02 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,202.26 / $2,754.23
| Facility | | $676.08 | $1,202.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $1,513.56
| Professional | | $676.08 | $1,000.00 | $1,513.56 |