- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.60 / $1,651.20 / $2,700.74
| Facility | | $438.60 | $1,651.20 | $2,700.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.10 / $394.40 / $493.00
| Professional | | $345.10 | $394.40 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.00 / $1,423.00 / $2,057.00
| Facility | | $716.00 | $1,423.00 | $2,057.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.16 / $2,117.16 / $2,117.16
| Professional | | $2,117.16 | $2,117.16 | $2,117.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.00 / $1,535.00 / $2,175.00
| Facility | | $716.00 | $1,535.00 | $2,175.00 |