- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.05 / $858.05 / $2,600.00
| Facility | | $858.05 | $858.05 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.44 / $858.05 / $999.80
| Professional | | $737.44 | $858.05 | $999.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.23 / $1,041.23 / $1,041.23
| Facility | | $1,041.23 | $1,041.23 | $1,041.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.30 / $1,283.50 / $5,297.48
| Professional | | $882.30 | $1,283.50 | $5,297.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.17 / $1,200.06 / $1,578.20
| Professional | | $721.17 | $1,200.06 | $1,578.20 |