- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $838.13 / $838.13 / $3,511.00
| Facility | | $838.13 | $838.13 | $3,511.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.04 / $838.13 / $866.46
| Professional | | $600.04 | $838.13 | $866.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.82 / $1,416.44 / $1,732.92
| Facility | | $338.82 | $1,416.44 | $1,732.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.76 / $1,598.49 / $6,755.28
| Professional | | $1,062.76 | $1,598.49 | $6,755.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.29 / $1,455.69 / $2,082.60
| Facility | | $1,042.29 | $1,455.69 | $2,082.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.40 / $1,159.40 / $1,672.80
| Professional | | $1,159.40 | $1,159.40 | $1,672.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.19 / $1,771.26 / $2,486.54
| Professional | | $974.19 | $1,771.26 | $2,486.54 |