- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $1,445.44
| Professional | | $1,000.00 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $389.05 / $467.74
| Professional | | $331.13 | $389.05 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $467.74
| Professional | | $389.05 | $389.05 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,737.80
| Professional | | $1,148.15 | $1,230.27 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,202.26 / $1,445.44
| Professional | | $389.05 | $1,202.26 | $1,445.44 |