- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,318.26 / $1,995.26
| Facility | | $645.65 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,380.38
| Professional | | $645.65 | $794.33 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,000.00
| Facility | | $588.84 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,071.52 / $1,513.56
| Professional | | $660.69 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,318.26 / $2,951.21
| Facility | | $616.60 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,778.28
| Professional | | $616.60 | $831.76 | $1,778.28 |