- 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
- $501.19 / $501.19 / $870.96
| Professional | | $501.19 | $501.19 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $1,621.81
| Professional | | $1,047.13 | $1,445.44 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,047.13
| Professional | | $831.76 | $831.76 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $851.14 / $3,388.44
| Facility | | $501.19 | $851.14 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $363.08 / $1,230.27
| Professional | | $302.00 | $363.08 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $724.44 / $1,047.13
| Professional | | $302.00 | $724.44 | $1,047.13 |