- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,348.96
| Facility | | $602.56 | $602.56 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $446.68 / $602.56
| Professional | | $331.13 | $446.68 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,659.59
| Facility | | $776.25 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,096.48 / $1,412.54
| Professional | | $398.11 | $1,096.48 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $3,467.37
| Facility | | $398.11 | $398.11 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $1,318.26
| Professional | | $812.83 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $363.08 / $1,071.52
| Professional | | $295.12 | $363.08 | $1,071.52 |