- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $562.34 / $660.69
| Professional | | $457.09 | $562.34 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $1,122.02
| Facility | | $812.83 | $912.01 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,318.26 / $3,162.28
| Facility | | $446.68 | $1,318.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $831.76 / $1,000.00
| Professional | | $794.33 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $912.01 / $1,258.93
| Professional | | $346.74 | $912.01 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,348.96
| Facility | | $676.08 | $676.08 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $691.83
| Professional | | $288.40 | $407.38 | $691.83 |