- 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
- $377.75 / $517.46 / $610.60
| Professional | | $377.75 | $517.46 | $610.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.06 / $711.44 / $1,738.19
| Professional | | $501.06 | $711.44 | $1,738.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,783.00 / $5,201.00
| Facility | | $650.00 | $1,783.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.53 / $542.64 / $811.38
| Professional | | $381.53 | $542.64 | $811.38 |