- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $841.10 / $1,340.15 / $4,736.00
| Facility | | $841.10 | $1,340.15 | $4,736.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.83 / $434.43 / $521.46
| Professional | | $280.83 | $434.43 | $521.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,732.57 / $1,732.57 / $1,732.57
| Facility | | $1,732.57 | $1,732.57 | $1,732.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.73 / $441.18 / $917.21
| Professional | | $315.73 | $441.18 | $917.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Facility | | $1,485.00 | $1,485.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.70 / $471.08 / $1,149.46
| Professional | | $396.70 | $471.08 | $1,149.46 |