- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.60 / $1,268.00 / $2,250.00
| Facility | | $840.60 | $1,268.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.64 / $840.60 / $1,043.21
| Professional | | $471.64 | $840.60 | $1,043.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.25 / $572.94 / $676.07
| Professional | | $418.25 | $572.94 | $676.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.06 / $736.90 / $1,723.84
| Professional | | $501.06 | $736.90 | $1,723.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.00 / $1,835.00 / $6,546.00
| Facility | | $657.00 | $1,835.00 | $6,546.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.60 / $542.64 / $811.38
| Professional | | $387.60 | $542.64 | $811.38 |