- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.22 / $1,167.73 / $1,400.00
| Facility | | $254.22 | $1,167.73 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.22 / $379.42 / $1,602.05
| Professional | | $254.22 | $379.42 | $1,602.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.83 / $293.83 / $293.83
| Facility | | $293.83 | $293.83 | $293.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.94 / $411.94 / $411.94
| Facility | | $411.94 | $411.94 | $411.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.00 / $1,099.21 / $2,807.56
| Professional | | $332.00 | $1,099.21 | $2,807.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.12 / $1,681.96 / $3,101.98
| Professional | | $961.12 | $1,681.96 | $3,101.98 |