- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $535.50 / $1,772.00 / $3,014.44
| Facility | | $535.50 | $1,772.00 | $3,014.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $318.75
| Professional | | $318.75 | $318.75 | $318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $469.64 / $524.89 / $679.47
| Facility | | $469.64 | $524.89 | $679.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.40 / $1,213.17 / $1,722.45
| Facility | | $435.40 | $1,213.17 | $1,722.45 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $400.04 / $600.00
| Facility | | $318.75 | $400.04 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.87 / $1,921.87 / $1,921.87
| Professional | | $1,921.87 | $1,921.87 | $1,921.87 |