- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $676.08 / $1,000.00
| Professional | | $489.78 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,995.26
| Facility | | $891.25 | $891.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,584.89
| Professional | | $660.69 | $660.69 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $1,513.56
| Facility | | $741.31 | $831.76 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $851.14
| Professional | | $371.54 | $562.34 | $851.14 |