- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $732.07 / $4,319.39
| Facility | | $318.75 | $732.07 | $4,319.39 |
- 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
- $597.51 / $1,088.76 / $1,195.00
| Professional | | $597.51 | $1,088.76 | $1,195.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,379.52 / $1,379.52 / $1,379.52
| Facility | | $1,379.52 | $1,379.52 | $1,379.52 |
- 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 |