- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $1,288.25
| Facility | | $501.19 | $501.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $501.19 / $645.65
| Professional | | $295.12 | $501.19 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $1,621.81
| Professional | | $954.99 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,023.29
| Professional | | $831.76 | $831.76 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $501.19 / $1,288.25
| Facility | | $295.12 | $501.19 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $724.44 / $1,445.44
| Professional | | $302.00 | $724.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $741.31 / $1,230.27
| Professional | | $302.00 | $741.31 | $1,230.27 |