- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.32 / $844.32 / $844.32
| Facility | | $844.32 | $844.32 | $844.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.55 / $844.32 / $2,748.48
| Professional | | $810.55 | $844.32 | $2,748.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.78 / $61.04 / $90.79
| Professional | | $45.78 | $61.04 | $90.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.93 / $111.93 / $1,127.27
| Professional | | $111.93 | $111.93 | $1,127.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.56 / $912.64 / $1,206.11
| Facility | | $774.56 | $912.64 | $1,206.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.30 / $628.30 / $628.30
| Professional | | $628.30 | $628.30 | $628.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.01 / $1,680.94 / $2,172.69
| Professional | | $1,057.01 | $1,680.94 | $2,172.69 |