- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $616.60 / $724.44
| Professional | | $436.52 | $616.60 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $977.24
| Facility | | $758.58 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $537.03 / $1,000.00
| Professional | | $354.81 | $537.03 | $1,000.00 |