- 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
- $458.18 / $1,331.90 / $1,765.50
| Facility | | $458.18 | $1,331.90 | $1,765.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.68 / $1,273.68 / $1,273.68
| Professional | | $1,273.68 | $1,273.68 | $1,273.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $425.00 / $663.00
| Facility | | $318.75 | $425.00 | $663.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.82 / $1,654.82 / $1,654.82
| Professional | | $1,654.82 | $1,654.82 | $1,654.82 |