- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $2,290.87
| Professional | | $758.58 | $977.24 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $6,456.54
| Facility | | $1,949.84 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,548.82
| Professional | | $1,047.13 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $5,128.61 / $8,128.31
| Facility | | $1,047.13 | $5,128.61 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,949.84
| Facility | | $812.83 | $1,000.00 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,025.60 / $7,943.28
| Facility | | $5,248.07 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $933.25 / $1,479.11
| Professional | | $93.33 | $933.25 | $1,479.11 |