- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $1,047.13 / $1,148.15
| Facility | | $275.42 | $1,047.13 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,148.15
| Professional | | $1,047.13 | $1,047.13 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $3,090.30
| Facility | | $1,047.13 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,047.13 / $1,348.96
| Professional | | $125.89 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,047.13
| Facility | | $707.95 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,047.13 / $1,047.13
| Professional | | $380.19 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $794.33
| Facility | | $302.00 | $436.52 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $302.00 / $1,000.00
| Professional | | $125.89 | $302.00 | $1,000.00 |