- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $738.00 / $1,446.16
| Facility | | $318.75 | $738.00 | $1,446.16 |
- 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
- $473.51 / $861.65 / $937.25
| Professional | | $473.51 | $861.65 | $937.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,236.33 / $1,236.33 / $1,236.33
| Facility | | $1,236.33 | $1,236.33 | $1,236.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.07 / $1,761.84 / $1,761.84
| Professional | | $1,189.07 | $1,761.84 | $1,761.84 |