- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.94 / $975.11 / $3,854.45
| Facility | | $398.94 | $975.11 | $3,854.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $425.00
| Professional | | $400.00 | $400.00 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.96 / $2,395.33 / $3,043.39
| Professional | | $1,935.96 | $2,395.33 | $3,043.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $997.34 / $3,391.77 / $3,394.40
| Facility | | $997.34 | $3,391.77 | $3,394.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.81 / $1,940.81 / $1,940.81
| Professional | | $1,940.81 | $1,940.81 | $1,940.81 |