- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $1,000.00
| Professional | | $478.63 | $660.69 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,949.84
| Facility | | $954.99 | $954.99 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,548.82
| Professional | | $691.83 | $691.83 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,479.11
| Facility | | $724.44 | $812.83 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $549.54 / $831.76
| Professional | | $363.08 | $549.54 | $831.76 |