- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.06 / $820.06 / $1,435.10
| Facility | | $820.06 | $820.06 | $1,435.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.32 / $820.06 / $863.36
| Professional | | $709.32 | $820.06 | $863.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.23 / $1,213.23 / $1,213.23
| Professional | | $1,213.23 | $1,213.23 | $1,213.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.45 / $293.45 / $293.45
| Professional | | $293.45 | $293.45 | $293.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,603.62 / $3,758.09
| Facility | | $100.00 | $1,603.62 | $3,758.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.58 / $1,273.94 / $2,195.25
| Professional | | $326.58 | $1,273.94 | $2,195.25 |