- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $1,412.54
| Professional | | $457.09 | $549.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $776.25
| Professional | | $549.54 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $1,230.27
| Professional | | $478.63 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $1,096.48
| Professional | | $549.54 | $616.60 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,000.00 / $3,548.13
| Facility | | $512.86 | $1,000.00 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $602.56 / $1,096.48
| Professional | | $416.87 | $602.56 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $851.14
| Professional | | $478.63 | $660.69 | $851.14 |