- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $804.79 / $1,477.00 / $3,000.00
| Facility | | $804.79 | $1,477.00 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.60 / $800.36 / $941.23
| Professional | | $567.60 | $800.36 | $941.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.37 / $830.47 / $879.32
| Professional | | $664.37 | $830.47 | $879.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.38 / $1,003.52 / $1,161.16
| Professional | | $709.38 | $1,003.52 | $1,161.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,828.00 / $6,957.00
| Facility | | $1,565.00 | $2,828.00 | $6,957.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.27 / $843.65 / $1,206.88
| Professional | | $599.27 | $843.65 | $1,206.88 |