- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $2,884.03
| Facility | | $645.65 | $645.65 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $501.19 / $645.65
| Professional | | $346.74 | $501.19 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $4,073.80 / $4,466.84
| Facility | | $741.31 | $4,073.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $416.87 / $645.65
| Professional | | $257.04 | $416.87 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $645.65 / $1,230.27
| Professional | | $281.84 | $645.65 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $776.25
| Professional | | $645.65 | $645.65 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,047.13
| Facility | | $645.65 | $645.65 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $616.60 / $954.99
| Professional | | $426.58 | $616.60 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $645.65 / $1,000.00
| Professional | | $389.05 | $645.65 | $1,000.00 |