- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,548.82 / $3,162.28
| Facility | | $812.83 | $1,548.82 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $831.76
| Professional | | $588.84 | $724.44 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,548.82 / $1,905.46
| Facility | | $758.58 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $977.24 / $1,230.27
| Professional | | $954.99 | $977.24 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $1,122.02
| Facility | | $501.19 | $645.65 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $831.76
| Professional | | $354.81 | $501.19 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $831.76 / $1,000.00
| Facility | | $354.81 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $831.76
| Professional | | $354.81 | $501.19 | $831.76 |