- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $979.03 / $1,448.95 / $3,132.89
| Facility | | $979.03 | $1,448.95 | $3,132.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.03 / $979.03 / $1,109.56
| Professional | | $979.03 | $979.03 | $1,109.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.49 / $848.49 / $3,487.29
| Facility | | $848.49 | $848.49 | $3,487.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.72 / $1,443.72 / $1,729.74
| Professional | | $1,443.72 | $1,443.72 | $1,729.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $965.97 / $1,305.36 / $2,193.02
| Facility | | $965.97 | $1,305.36 | $2,193.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $548.26 / $4,901.96
| Professional | | $548.26 | $548.26 | $4,901.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $548.26 / $1,305.36
| Professional | | $548.26 | $548.26 | $1,305.36 |