- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.25 / $307.25 / $2,347.11
| Facility | | $307.25 | $307.25 | $2,347.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.25 / $307.25 / $412.59
| Professional | | $307.25 | $307.25 | $412.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.86 / $2,627.46 / $2,948.56
| Professional | | $877.86 | $2,627.46 | $2,948.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.36 / $1,513.35 / $1,902.92
| Professional | | $1,498.36 | $1,513.35 | $1,902.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.25 / $412.59 / $2,347.11
| Facility | | $307.25 | $412.59 | $2,347.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.88 / $636.45 / $1,564.74
| Professional | | $252.88 | $636.45 | $1,564.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.35 / $614.50 / $1,564.74
| Professional | | $184.35 | $614.50 | $1,564.74 |