- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $614.41 / $614.41 / $908.28
| Facility | | $614.41 | $614.41 | $908.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.41 / $853.22 / $908.28
| Professional | | $614.41 | $853.22 | $908.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.69 / $985.04 / $1,033.06
| Professional | | $815.69 | $985.04 | $1,033.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.25 / $203.46 / $1,897.86
| Facility | | $105.25 | $203.46 | $1,897.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.31 / $203.46 / $2,322.42
| Professional | | $133.31 | $203.46 | $2,322.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $1,560.25
| Facility | | $606.51 | $606.51 | $1,560.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.53 / $606.51 / $1,160.03
| Professional | | $515.53 | $606.51 | $1,160.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,007.61
| Professional | | $100.00 | $100.00 | $1,007.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.20 / $697.80 / $1,040.00
| Professional | | $465.20 | $697.80 | $1,040.00 |