- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.65 / $942.78 / $1,697.00
| Facility | | $785.65 | $942.78 | $1,697.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.65 / $785.65 / $785.65
| Professional | | $785.65 | $785.65 | $785.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.08 / $870.08 / $870.08
| Professional | | $870.08 | $870.08 | $870.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.58 / $143.86 / $451.85
| Facility | | $61.58 | $143.86 | $451.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.02 / $785.65 / $1,060.63
| Facility | | $319.02 | $785.65 | $1,060.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.00 / $700.00 / $4,017.75
| Professional | | $700.00 | $700.00 | $4,017.75 |