- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $1,125.00 / $1,836.00
| Facility | | $318.75 | $1,125.00 | $1,836.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $475.00
| Professional | | $318.75 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.36 / $1,070.25 / $1,244.73
| Facility | | $398.36 | $1,070.25 | $1,244.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.77 / $1,098.77 / $1,098.77
| Professional | | $1,098.77 | $1,098.77 | $1,098.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $425.63 / $663.00
| Facility | | $318.75 | $425.63 | $663.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.33 / $1,352.33 / $1,352.33
| Professional | | $1,352.33 | $1,352.33 | $1,352.33 |