- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $423.77 / $1,025.52 / $2,599.00
| Facility | | $423.77 | $1,025.52 | $2,599.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.77 / $423.77 / $1,037.28
| Professional | | $423.77 | $423.77 | $1,037.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,573.00 / $6,781.94 / $6,781.94
| Facility | | $2,573.00 | $6,781.94 | $6,781.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.72 / $466.51 / $872.66
| Professional | | $389.72 | $466.51 | $872.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.60 / $440.31 / $975.58
| Professional | | $317.60 | $440.31 | $975.58 |