- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $727.02 / $900.00
| Facility | | $318.75 | $727.02 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $425.00
| Professional | | $318.75 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $706.00 / $1,000.00
| Facility | | $510.00 | $706.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.01 / $590.90 / $622.00
| Professional | | $311.01 | $590.90 | $622.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.64 / $975.64 / $975.64
| Facility | | $975.64 | $975.64 | $975.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.15 / $1,338.15 / $1,338.15
| Professional | | $1,338.15 | $1,338.15 | $1,338.15 |